Provider Demographics
NPI:1093353096
Name:RAINWOOD HEALING SPACE-LLC
Entity Type:Organization
Organization Name:RAINWOOD HEALING SPACE-LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DUALLY LICENSED THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOODWIN-DALY
Authorized Official - Suffix:
Authorized Official - Credentials:PLMHP, PLADC
Authorized Official - Phone:402-813-8244
Mailing Address - Street 1:9910 N 48TH ST STE 111
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68152-1548
Mailing Address - Country:US
Mailing Address - Phone:402-813-8244
Mailing Address - Fax:
Practice Address - Street 1:9910 N 48TH ST STE 111
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68152-1548
Practice Address - Country:US
Practice Address - Phone:402-813-8244
Practice Address - Fax:844-486-0274
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RAINWOOD HEALING SPACE-LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-20
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026811800Medicaid