Healthcare Provider Details

I. General information

NPI: 1750654166
Provider Name (Legal Business Name): FALLBROOK BEHAVIORAL HEALTH, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 FALLBROOK BLVD STE 100
LINCOLN NE
68521-4637
US

IV. Provider business mailing address

755 FALLBROOK BLVD STE 100
LINCOLN NE
68521-4637
US

V. Phone/Fax

Practice location:
  • Phone: 402-875-0632
  • Fax: 402-438-2107
Mailing address:
  • Phone: 402-875-0632
  • Fax: 402-438-2107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number747
License Number StateNE

VIII. Authorized Official

Name: DR. THOMAS J TIEGS
Title or Position: PRESIDENT
Credential: PHD
Phone: 402-875-0632