Basic Information
| Provider Information | |||||||||
| NPI: | 1013218619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LIMHP, LADC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MADSEN | ||||||||
| OtherFirstName: | HEIDI | ||||||||
| OtherMiddleName: | LYNNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3300 N 60TH ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681043402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025540520 | ||||||||
| FaxNumber: | 4025518797 | ||||||||
| Practice Location | |||||||||
| Address1: | 13460 WALSH DR | ||||||||
| Address2: | |||||||||
| City: | BOYS TOWN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680107529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025983358 | ||||||||
| FaxNumber: | 4024983375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2010 | ||||||||
| LastUpdateDate: | 10/11/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 1100 | NE | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 100257453-00 | 05 | NE | MEDICAID | 470376606-31 | 05 | NE | MEDICAID | 100261397-00 | 05 | NE | MEDICAID |