Basic Information
| Provider Information | |||||||||
| NPI: | 1184790776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLISON AMBURN | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA LADC LMHP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RINGEISEN | ||||||||
| OtherFirstName: | DEBORAH | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA CADAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3300 N 60TH ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025540520 | ||||||||
| FaxNumber: | 4025518797 | ||||||||
| Practice Location | |||||||||
| Address1: | 3020 18T STREET | ||||||||
| Address2: | STE 17 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025633833 | ||||||||
| FaxNumber: | 4025628714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 269 | NE | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 1380 | NE | X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 100253156100 | 05 | NE | MEDICAID | 47037661202 | 05 | NE | MEDICAID | 85513 | 01 | NE | BCBS | OTHER |