Basic Information
Provider Information | |||||||||
NPI: | 1942415203 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CONWAY | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BACON | ||||||||
OtherFirstName: | HEATHER | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2633 P ST | ||||||||
Address2: |   | ||||||||
City: | LINCOLN | ||||||||
State: | NE | ||||||||
PostalCode: | 685033528 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4024758717 | ||||||||
FaxNumber: | 4024758726 | ||||||||
Practice Location | |||||||||
Address1: | 1000 S 13TH ST | ||||||||
Address2: |   | ||||||||
City: | LINCOLN | ||||||||
State: | NE | ||||||||
PostalCode: | 685083533 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4024755161 | ||||||||
FaxNumber: | 4024753300 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X |   |   | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.