Healthcare Provider Details

I. General information

NPI: 1639161904
Provider Name (Legal Business Name): PRAIRIE PSYCHOLOGICAL SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E 39TH ST
SOUTH SIOUX CITY NE
68776-3445
US

IV. Provider business mailing address

625 E 39TH ST
SOUTH SIOUX CITY NE
68776-3445
US

V. Phone/Fax

Practice location:
  • Phone: 402-494-0040
  • Fax: 402-494-0050
Mailing address:
  • Phone: 402-494-0040
  • Fax: 402-494-0050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number371
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1187
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1729
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number531
License Number StateNE
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number808
License Number StateNE

VIII. Authorized Official

Name: MS. TWILA L PRESTON
Title or Position: OWNER
Credential: PHD
Phone: 402-494-0040