Provider Demographics
NPI:1003310061
Name:PINE LAKE BEHAVIORAL HEALTH, LLC.
Entity Type:Organization
Organization Name:PINE LAKE BEHAVIORAL HEALTH, LLC.
Other - Org Name:PINE LAKE BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:LIPC, LADC
Authorized Official - Phone:402-434-2730
Mailing Address - Street 1:9100 ANDERMATT DR STE 1
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68526-6700
Mailing Address - Country:US
Mailing Address - Phone:402-434-2730
Mailing Address - Fax:402-434-3970
Practice Address - Street 1:9100 ANDERMATT DRIVE SUITE 1
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68526-0000
Practice Address - Country:US
Practice Address - Phone:402-434-2730
Practice Address - Fax:402-434-3970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-22
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE261Q00000X
261QM0801X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026721200Medicaid
NENA3283OtherMEDICARE PTAN
NE10026721201Medicaid
NEDY5949OtherRR MEDICARE PTAN