Provider Demographics
NPI:1114405370
Name:KHANTHANSENE, BONN
Entity Type:Individual
Prefix:
First Name:BONN
Middle Name:
Last Name:KHANTHANSENE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 S 24TH ST STE 230
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-1226
Mailing Address - Country:US
Mailing Address - Phone:402-978-5644
Mailing Address - Fax:402-591-5075
Practice Address - Street 1:2301 O ST STE 1
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-1100
Practice Address - Country:US
Practice Address - Phone:402-441-7940
Practice Address - Fax:402-441-8625
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health