MEDICARE: INFINITE CHANGE FAMILY THERAPY CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093295065
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INFINITE CHANGE FAMILY THERAPY CENTER LLC

Provider Business Mailing Address
First Line	:	245 S 84TH ST STE L101
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68510-2601
Country	:	US
Telephone Number	:	402-421-1182
Fax Number	:	402-465-8717

Provider Business Practice Location Address
First Line	:	245 S 84TH ST STE L101
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68510-2601
Country	:	US
Telephone Number	:	402-421-1182
Fax Number	:	402-465-8717

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	KADRA OMEROVIC
Credential	:
Telephone Number	:	402-421-1182

Provider Enumeration Date	:	08/18/2018
Last Update Date	:	08/18/2018

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