Healthcare Provider Details

I. General information

NPI: 1174691935
Provider Name (Legal Business Name): FAMILY LIFE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 EAST 6TH
LEXINGTON NE
68850
US

IV. Provider business mailing address

207 EAST 6TH PO BOX 714
LEXINGTON NE
68850
US

V. Phone/Fax

Practice location:
  • Phone: 308-324-5623
  • Fax: 308-324-5624
Mailing address:
  • Phone: 308-324-5623
  • Fax: 308-324-5624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1071
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number72
License Number StateNE

VIII. Authorized Official

Name: MRS. WANDA L ENNS
Title or Position: OWNER
Credential: PHD
Phone: 308-236-5006