=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801302948
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEATON COUNSELING CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2017
-----------------------------------------------------
Last Update Date | 01/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6818 CHANDON DR
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68526-6056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-617-0317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6818 CHANDON DR
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68526-6056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-617-0317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JESSE S HEATON
-----------------------------------------------------
Credential | MS LMHP
-----------------------------------------------------
Telephone | 402-617-0317
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number | 4845
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 4845
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 4845
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 4845
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------