Provider Demographics
NPI:1396018198
Name:SHANE CROCKETT
Entity Type:Organization
Organization Name:SHANE CROCKETT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:MAYNARD
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:LIMHP,LMHP
Authorized Official - Phone:402-488-1032
Mailing Address - Street 1:8101 'O' STREET
Mailing Address - Street 2:SUITE 214
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2647
Mailing Address - Country:US
Mailing Address - Phone:402-488-1032
Mailing Address - Fax:402-484-8545
Practice Address - Street 1:8101 'O' STREET
Practice Address - Street 2:SUITE 214
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2647
Practice Address - Country:US
Practice Address - Phone:402-488-1032
Practice Address - Fax:402-484-8545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE834251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100251092-00Medicaid