Healthcare Provider Details

I. General information

NPI: 1114405370
Provider Name (Legal Business Name): BONN KHANTHANSENE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 O ST STE 1
LINCOLN NE
68510-1100
US

IV. Provider business mailing address

124 S 24TH ST STE 230
OMAHA NE
68102-1226
US

V. Phone/Fax

Practice location:
  • Phone: 402-441-7940
  • Fax: 402-441-8625
Mailing address:
  • Phone: 402-978-5644
  • Fax: 402-591-5075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: