Healthcare Provider Details

I. General information

NPI: 1073995619
Provider Name (Legal Business Name): MARY HEPBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 09/14/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5917 MAPLE ST
OMAHA NE
68104-4101
US

IV. Provider business mailing address

4907 BURT ST
OMAHA NE
68132-2413
US

V. Phone/Fax

Practice location:
  • Phone: 402-686-9263
  • Fax:
Mailing address:
  • Phone: 515-207-2964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: