Provider Demographics
NPI:1043224660
Name:PAINE, MARY LOU (PHD, LP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:PAINE
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 S 70TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-1576
Mailing Address - Country:US
Mailing Address - Phone:402-488-0077
Mailing Address - Fax:402-488-0017
Practice Address - Street 1:1550 S 70TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1576
Practice Address - Country:US
Practice Address - Phone:402-488-0077
Practice Address - Fax:402-488-0017
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE559103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE5156OtherMIDLANDS CHOICE
NE98378OtherBCBS AUXILIARY
NE80077OtherBLUE CROSS BLUE SHIELD
NE10025451300Medicaid
NE275886Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NE5156OtherMIDLANDS CHOICE
NEP00208487Medicare ID - Type UnspecifiedRAILROAD