=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992049852
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFEWORKS WELLNESS, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2012
-----------------------------------------------------
Last Update Date | 01/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 N MINNESOTA AVE
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68901-5254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-469-3885
-----------------------------------------------------
Fax | 866-567-9221
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 N MINNESOTA AVE
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68901-5254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-469-3885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | STEPHANIE COBB KINNEY
-----------------------------------------------------
Credential | LIMHP
-----------------------------------------------------
Telephone | 402-469-3885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 1664
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 739
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------