Basic Information
| Provider Information | |||||||||
| NPI: | 1841575073 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OUR SUPPORTED HOMES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20066 S 190TH ST | ||||||||
| Address2: | |||||||||
| City: | ADAMS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 683013023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023288833 | ||||||||
| FaxNumber: | 4023282921 | ||||||||
| Practice Location | |||||||||
| Address1: | 20066 S 190TH ST | ||||||||
| Address2: | |||||||||
| City: | ADAMS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 683013023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023288833 | ||||||||
| FaxNumber: | 4023282921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2011 | ||||||||
| LastUpdateDate: | 05/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | LORENSON | ||||||||
| AuthorizedOfficialFirstName: | TARA | ||||||||
| AuthorizedOfficialMiddleName: | MARY | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4025400135 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | LMIHP, MSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 911 | NE | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.