Basic Information
| Provider Information | |||||||||
| NPI: | 1326345984 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTERPOINTE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY SUPPORT SA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2633 P ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685033528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024758717 | ||||||||
| FaxNumber: | 4024755683 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 S 13TH ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685083533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024755161 | ||||||||
| FaxNumber: | 4024753300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2011 | ||||||||
| LastUpdateDate: | 02/17/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | TOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4024758717 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | J.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 10025213000 | 05 | NE | MEDICAID |