=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790156040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORIGINS HEALTH AND WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2015
-----------------------------------------------------
Last Update Date | 10/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2123 WINTHROP RD SUITE B
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68502-4156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-489-9990
-----------------------------------------------------
Fax | 402-261-9202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2123 WINTHROP RD SUITE B
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68502-4156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-489-9990
-----------------------------------------------------
Fax | 402-261-9202
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TRICIA KAY MONZON
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 402-489-9990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | LIMHP 1088; LADC 697
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------