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General NPI Number Information
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NPI Number | 1396018198
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Entity Type | Organization
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Legal Business Name | SHANE CROCKETT
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Dates
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Enumeration Date | 02/10/2012
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Last Update Date | 02/10/2012
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Provider Practice Location Address
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Address Line | 8101 'O' STREET SUITE 214
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City | LINCOLN
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State | NE
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Zip | 68510-2647
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Country | US
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Telephone | 402-488-1032
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Fax | 402-484-8545
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Provider Business Mailing Address
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Address Line | 8101 'O' STREET SUITE 214
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City | LINCOLN
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State | NE
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Zip | 68510-2647
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Country | US
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Telephone | 402-488-1032
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Fax | 402-484-8545
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Authorized Official
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Title or Position | PSYCHOTHERAPIST
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Name | MR. SHANE MAYNARD CROCKETT
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Credential | LIMHP,LMHP
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Telephone | 402-488-1032
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 834
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License Number State | NE
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