=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508858648
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHERINE ANN NICOLARSEN LCSW LMHP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2005
-----------------------------------------------------
Last Update Date | 02/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 AMERICAN PKWY
-----------------------------------------------------
City | PAPILLION
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68046-6270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-339-2544
-----------------------------------------------------
Fax | 402-339-4358
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4559 SHIRLEY ST
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-558-3857
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 2946
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 1177
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------