=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598821001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISINET INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 W 2ND ST
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68801-5822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-398-4662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1020 W 2ND ST
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68801-5822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-398-4662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MRS. TINA MARIE BOURLAND
-----------------------------------------------------
Credential | PLMHP
-----------------------------------------------------
Telephone | 308-398-4662
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 7938
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------