Basic Information
| Provider Information | |||||||||
| NPI: | 1356454276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANNING | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LIMHP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOZAK | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LIMHP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4920 SO 30TH STREET | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681071656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027344110 | ||||||||
| FaxNumber: | 4027343990 | ||||||||
| Practice Location | |||||||||
| Address1: | 12020 SHAMROCK PLAZA | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026167946 | ||||||||
| FaxNumber: | 4027343990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 12/20/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 1866 | NE | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 1866 | NE | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | 654 | NE | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 47037660433 | 05 | NE | MEDICAID |