Basic Information
| Provider Information | |||||||||
| NPI: | 1568780732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAMLIAN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSYD, BCBA-D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 985450 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681985450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025596408 | ||||||||
| FaxNumber: | 4025595737 | ||||||||
| Practice Location | |||||||||
| Address1: | 3775 45TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 686014427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025647200 | ||||||||
| FaxNumber: | 4025595737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2010 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-10-7098 | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103T00000X | 856 | NE | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.