Provider Demographics
NPI:1295180297
Name:FENICLE, KETURAH (CSS)
Entity Type:Individual
Prefix:
First Name:KETURAH
Middle Name:
Last Name:FENICLE
Suffix:
Gender:F
Credentials:CSS
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
Mailing Address - Street 2:SUITE 230
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-1226
Mailing Address - Country:US
Mailing Address - Phone:402-342-7007
Mailing Address - Fax:402-591-5075
Practice Address - Street 1:120 S 24TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-1213
Practice Address - Country:US
Practice Address - Phone:402-342-7007
Practice Address - Fax:402-591-5075
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor