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General NPI Number Information
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NPI Number | 1174691935
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Entity Type | Organization
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Legal Business Name | FAMILY LIFE CLINIC
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Dates
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Enumeration Date | 12/01/2006
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Last Update Date | 06/18/2008
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Provider Practice Location Address
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Address Line | 207 EAST 6TH
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City | LEXINGTON
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State | NE
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Zip | 68850
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Country | US
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Telephone | 308-324-5623
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Fax | 308-324-5624
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Provider Business Mailing Address
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Address Line | 207 EAST 6TH PO BOX 714
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City | LEXINGTON
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State | NE
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Zip | 68850
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Country | US
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Telephone | 308-324-5623
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Fax | 308-324-5624
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Authorized Official
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Title or Position | OWNER
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Name | MRS. WANDA L ENNS
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Credential | PHD
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Telephone | 308-236-5006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 72
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 1071
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License Number State | NE
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