Provider Demographics
NPI:1104222041
Name:STIDHAM, KIRSTEN (LIMHP)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:LIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2036 N 63RD ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-4712
Mailing Address - Country:US
Mailing Address - Phone:515-451-7523
Mailing Address - Fax:402-933-9998
Practice Address - Street 1:8922 CUMING ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2732
Practice Address - Country:US
Practice Address - Phone:402-926-4373
Practice Address - Fax:402-926-3898
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10393101YM0800X
NE2136101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health