Healthcare Provider Details

I. General information

NPI: 1003310061
Provider Name (Legal Business Name): PINE LAKE BEHAVIORAL HEALTH, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 ANDERMATT DRIVE SUITE 1
LINCOLN NE
68526-0000
US

IV. Provider business mailing address

9100 ANDERMATT DR STE 1
LINCOLN NE
68526-6700
US

V. Phone/Fax

Practice location:
  • Phone: 402-434-2730
  • Fax: 402-434-3970
Mailing address:
  • Phone: 402-434-2730
  • Fax: 402-434-3970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: JARED WADE RAY
Title or Position: DIRECTOR OF OPERATIONS
Credential: LIPC, LADC
Phone: 402-434-2730