=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356885024
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRO CARE MENTAL HEALTH INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2016
-----------------------------------------------------
Last Update Date | 12/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 421 S 243RD ST
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68069-4704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-980-1697
-----------------------------------------------------
Fax | 402-896-3695
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 421 S 243RD ST
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68069-4704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-980-1697
-----------------------------------------------------
Fax | 402-896-3695
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEAN A LIST
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 402-980-1697
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 110412
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------