Provider Demographics
NPI:1316185812
Name:BEHAVIORAL MEDICINE CLINIC PC
Entity Type:Organization
Organization Name:BEHAVIORAL MEDICINE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:402-729-6379
Mailing Address - Street 1:510 D ST STE 2
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:NE
Mailing Address - Zip Code:68352-2318
Mailing Address - Country:US
Mailing Address - Phone:402-729-6379
Mailing Address - Fax:402-729-4094
Practice Address - Street 1:510 D ST STE 2
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:NE
Practice Address - Zip Code:68352-2318
Practice Address - Country:US
Practice Address - Phone:402-729-6379
Practice Address - Fax:402-729-4094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE439103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10024987500Medicaid
NE274156Medicare PIN