Healthcare Provider Details

I. General information

NPI: 1023257854
Provider Name (Legal Business Name): MR. RUSSELL J ROSENQUIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 N 100TH ST
OMAHA NE
68134-3724
US

IV. Provider business mailing address

4205 N 100TH ST
OMAHA NE
68134-3724
US

V. Phone/Fax

Practice location:
  • Phone: 402-619-1079
  • Fax:
Mailing address:
  • Phone: 402-619-1079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number#675
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number675
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number#653
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: