MEDICARE: IM HEBRANK PSYCHOTHERAPY

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1508328733
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IM HEBRANK PSYCHOTHERAPY

Provider Business Mailing Address
First Line	:	1406 FORT CROOK RD S STE 401
Second Line	:
City	:	BELLEVUE
State	:	NE
Zip	:	68005-2980
Country	:	US
Telephone Number	:	402-541-9698
Fax Number	:

Provider Business Practice Location Address
First Line	:	1406 FORT CROOK RD S STE 401
Second Line	:
City	:	BELLEVUE
State	:	NE
Zip	:	68005-2980
Country	:	US
Telephone Number	:	402-541-9698
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	IDA MARIE HEBRANK
Credential	:	LIMHP, CMSW, LADC
Telephone Number	:	402-541-9698

Provider Enumeration Date	:	04/05/2019
Last Update Date	:	04/05/2019

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