MEDICARE: MR. HARRY D WASHINGTON III PLADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	P-1710	NE

General Provider Information

NPI Number	:	1154930386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HARRY D WASHINGTON III PLADC

Provider Business Mailing Address
First Line	:	5325 N 27TH AVE
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68111-1712
Country	:	US
Telephone Number	:	402-706-0267
Fax Number	:

Provider Business Practice Location Address
First Line	:	1299 FARNAM
Second Line	:	NULL
City	:	OMAHA
State	:	NE
Zip	:	68105-6811
Country	:	US
Telephone Number	:	402-706-0267
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2020
Last Update Date	:	07/23/2020

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