=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447318258
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EARLY INTERVENTIONS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 GOLD COAST RD. STE. 600
-----------------------------------------------------
City | PAPILLION
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68046-5811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-597-9378
-----------------------------------------------------
Fax | 402-597-9253
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1401 GOLD COAST RD. STE. 600
-----------------------------------------------------
City | PAPILLION
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68046-5811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. AMANDA J CERVANTES
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 402-597-9378
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------