MEDICARE: PRAIRIE HOPE COUNSELING, 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	251S00000X	Community/Behavioral Health Agency	004011365749	NE

General Provider Information

NPI Number	:	1841544228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRAIRIE HOPE COUNSELING, LLC

Provider Business Mailing Address
First Line	:	810 LONG RD
Second Line	:
City	:	HAY SPRINGS
State	:	NE
Zip	:	69347-2504
Country	:	US
Telephone Number	:	308-638-4411
Fax Number	:	308-432-4003

Provider Business Practice Location Address
First Line	:	810 LONG RD
Second Line	:
City	:	HAY SPRINGS
State	:	NE
Zip	:	69347-2504
Country	:	US
Telephone Number	:	308-638-4411
Fax Number	:	308-432-4003

Authorized Official
Title or Position	:	SOLE PROPRIETER
Name	:	TRACY DIERKSEN
Credential	:	MSW, LCSW, PADC, RN
Telephone Number	:	308-430-1023

Provider Enumeration Date	:	11/06/2012
Last Update Date	:	12/31/2014

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