Healthcare Provider Details

I. General information

NPI: 1669928602
Provider Name (Legal Business Name): RYAN JOHN MAHNKE MS, PLMHP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 E 22ND ST
FREMONT NE
68025-2661
US

IV. Provider business mailing address

4102 WOOLWORTH AVE
OMAHA NE
68105-1851
US

V. Phone/Fax

Practice location:
  • Phone: 402-214-9254
  • Fax: 402-727-4288
Mailing address:
  • Phone: 402-444-7608
  • Fax: 402-996-8171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10965
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12706
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: