Healthcare Provider Details

I. General information

NPI: 1710366091
Provider Name (Legal Business Name): THERAHA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12020 SHAMROCK PLZ SUITE 200
OMAHA NE
68154-3537
US

IV. Provider business mailing address

12912 SCOTT ST
OMAHA NE
68142-1770
US

V. Phone/Fax

Practice location:
  • Phone: 402-850-7200
  • Fax:
Mailing address:
  • Phone: 402-850-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number984
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2013
License Number StateNE

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KIRA TALBOTT
Title or Position: OWNER
Credential: LMHP, LADC
Phone: 402-850-7200