MEDICARE: FALL FORWARD

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1629695606
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FALL FORWARD

Provider Business Mailing Address
First Line	:	PO BOX 105
Second Line	:
City	:	DONIPHAN
State	:	NE
Zip	:	68832-0105
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	312 N ELM ST STE 115
Second Line	:
City	:	GRAND ISLAND
State	:	NE
Zip	:	68801-4509
Country	:	US
Telephone Number	:	402-481-5597
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SOCIAL WORKER
Name	:	LISA BARNES
Credential	:	LICSW
Telephone Number	:	402-481-5597

Provider Enumeration Date	:	06/25/2020
Last Update Date	:	06/25/2020

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Directions to “FALL FORWARD ” Practice Location

Language	Start Address	Practice Location

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