=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447794219
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY NETWORK PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2016
-----------------------------------------------------
Last Update Date | 12/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 W 33RD ST
-----------------------------------------------------
City | KEARNEY
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68845-3460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-236-7545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 W 33RD ST
-----------------------------------------------------
City | KEARNEY
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68845-3460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-236-7545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. KELLY JO SHADA
-----------------------------------------------------
Credential | LMHP
-----------------------------------------------------
Telephone | 308-236-7545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 423
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------