Healthcare Provider Details

I. General information

NPI: 1356454276
Provider Name (Legal Business Name): MARY ELLEN MANNING LIMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY ELLEN BOZAK LIMHP

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12020 SHAMROCK PLAZA SUITE 200
OMAHA NE
68154
US

IV. Provider business mailing address

4920 SO 30TH STREET SUITE 103
OMAHA NE
68107-1656
US

V. Phone/Fax

Practice location:
  • Phone: 402-616-7946
  • Fax: 402-734-3990
Mailing address:
  • Phone: 402-734-4110
  • Fax: 402-734-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1866
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1866
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number654
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: