=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417542630
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEFY THE CYCLE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2021
-----------------------------------------------------
Last Update Date | 03/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4535 NORMAL BLVD STE 295
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68506-2890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-853-6686
-----------------------------------------------------
Fax | 888-972-3644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4535 NORMAL BLVD STE 295
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68506-2890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-853-6686
-----------------------------------------------------
Fax | 888-972-3644
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | AMBER ZEISLER
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 402-853-6686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------