Healthcare Provider Details

I. General information

NPI: 1033009337
Provider Name (Legal Business Name): SAMUEL KINGERY
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3833 S 14TH ST
LINCOLN NE
68502-5340
US

IV. Provider business mailing address

4749 DUXHALL DR
LINCOLN NE
68516-3116
US

V. Phone/Fax

Practice location:
  • Phone: 402-937-8323
  • Fax:
Mailing address:
  • Phone: 402-217-5605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14499
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: