Basic Information
| Provider Information | |||||||||
| NPI: | 1417123464 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASILLAS | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | MYRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4545 S 86TH ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685269227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024836990 | ||||||||
| FaxNumber: | 4024837045 | ||||||||
| Practice Location | |||||||||
| Address1: | 4545 S 86TH ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685269227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024836990 | ||||||||
| FaxNumber: | 4024837045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2008 | ||||||||
| LastUpdateDate: | 04/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 8188 | NE | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 470798717-26 | 05 | NE | MEDICAID | 470798717-27 | 05 | NE | MEDICAID | 470798717-29 | 05 | NE | MEDICAID | 84757 | 01 | NE | BLUE CROSS AND BLUE SHIELD | OTHER |