Healthcare Provider Details

I. General information

NPI: 1689265985
Provider Name (Legal Business Name): DIANE MARIE MANDINA-MORRILL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2021
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S 70TH ST STE 200
LINCOLN NE
68506-1568
US

IV. Provider business mailing address

1600 S 70TH ST STE 200
LINCOLN NE
68506-1568
US

V. Phone/Fax

Practice location:
  • Phone: 402-937-8323
  • Fax: 402-937-8324
Mailing address:
  • Phone: 402-937-8323
  • Fax: 402-937-8324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12461
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: