Healthcare Provider Details

I. General information

NPI: 1033873211
Provider Name (Legal Business Name): RESTORATION PSYCHOTHERAPY & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4645 NORMAL BLVD STE 272
LINCOLN NE
68506-5823
US

IV. Provider business mailing address

4645 NORMAL BLVD STE 272
LINCOLN NE
68506-5823
US

V. Phone/Fax

Practice location:
  • Phone: 602-770-8836
  • Fax:
Mailing address:
  • Phone: 602-770-8836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY MONTAG
Title or Position: CO-FOUNDER
Credential: LIMHP
Phone: 602-770-8836