Healthcare Provider Details

I. General information

NPI: 1962762195
Provider Name (Legal Business Name): WILLIAMSBURG BEHAVIORAL PSYCHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 UNION DR STE 206
LINCOLN NE
68516-6652
US

IV. Provider business mailing address

3801 UNION DR STE 206
LINCOLN NE
68516-6652
US

V. Phone/Fax

Practice location:
  • Phone: 402-489-2218
  • Fax: 402-489-3666
Mailing address:
  • Phone: 402-489-2218
  • Fax: 402-489-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number766
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number261
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number528
License Number StateNE

VIII. Authorized Official

Name: CARYLL PLAMER WILSON
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 402-489-2218