Basic Information
| Provider Information | |||||||||
| NPI: | 1164446605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZLOMKE | ||||||||
| FirstName: | LELAND | ||||||||
| MiddleName: | CARL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5321 S 78TH ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685166356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028061700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 110 N 9TH ST | ||||||||
| Address2: | |||||||||
| City: | BEATRICE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 683104009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024836990 | ||||||||
| FaxNumber: | 4024837045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist | 103TF0200X | N | Behavioral Health & Social Service Providers | Psychologist | Forensic | 103TM1800X | N | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 103TB0200X | N | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC1900X | N | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103TC2200X | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 245672 | 01 | NE | MIDLANDS CHOICE | OTHER | P00963834 | 01 | NE | MEDICARE RAILROAD | OTHER | 49038 | 01 | NE | BCBS | OTHER | 90095 | 01 | NE | BCBS AUXILLARY | OTHER |