Provider Demographics
NPI:1437642550
Name:AUSTIN, WILLIE R
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:R
Last Name:AUSTIN
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 1:1941 S 42ND ST STE 540
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-2986
Mailing Address - Country:US
Mailing Address - Phone:402-452-0102
Mailing Address - Fax:402-933-6068
Practice Address - Street 1:1941 S 42ND ST STE 540
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-2986
Practice Address - Country:US
Practice Address - Phone:402-452-0102
Practice Address - Fax:402-933-6068
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1207101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)