Basic Information
| Provider Information | |||||||||
| NPI: | 1033539580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURNS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | LIMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 LEAVENWORTH ST. | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681022933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026144870 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2740 N CLARKSON ST | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680257703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027210951 | ||||||||
| FaxNumber: | 4027210804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2014 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2230 | NE | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 2230 | 01 | NE | LIMHP LICENSE | OTHER | 10025851800 | 05 | NE | MEDICAID |