Healthcare Provider Details

I. General information

NPI: 1396209623
Provider Name (Legal Business Name): PEARL STREET COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2019
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 N PEARL STREET
WAYNE NE
68787
US

IV. Provider business mailing address

85365 567TH AVENUE
WINSIDE NE
68790
US

V. Phone/Fax

Practice location:
  • Phone: 402-286-4891
  • Fax:
Mailing address:
  • Phone: 402-286-4891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. LIN M BRUMMELS
Title or Position: AUTHORIZED AGENT
Credential: LMHP, CDC
Phone: 402-286-4891