=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023873577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHNEBRASKA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2024
-----------------------------------------------------
Last Update Date | 09/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18651 WEBSTER CIR
-----------------------------------------------------
City | ELKHORN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68022-3948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 531-272-8322
-----------------------------------------------------
Fax | 531-272-8823
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18651 WEBSTER CIR
-----------------------------------------------------
City | ELKHORN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68022-3948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 531-272-8322
-----------------------------------------------------
Fax | 531-272-8823
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. PAUL M WILKEN
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 531-272-8322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------