Basic Information
| Provider Information | |||||||||
| NPI: | 1861859852 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHRADER | ||||||||
| FirstName: | BRITNI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1941 S 42ND ST | ||||||||
| Address2: | SUITE 328 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681052939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026148444 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8715 OAK ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681243051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023330898 | ||||||||
| FaxNumber: | 4023330988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2016 | ||||||||
| LastUpdateDate: | 12/31/2018 | ||||||||
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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 | 101YM0800X | 10759 | NE | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 10025317600 | 05 | NE | MEDICAID |