Provider Demographics
NPI:1447794219
Name:FAMILY NETWORK PC
Entity Type:Organization
Organization Name:FAMILY NETWORK PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:SHADA
Authorized Official - Suffix:
Authorized Official - Credentials:LMHP
Authorized Official - Phone:308-236-7545
Mailing Address - Street 1:415 W 33RD ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-3460
Mailing Address - Country:US
Mailing Address - Phone:308-236-7545
Mailing Address - Fax:
Practice Address - Street 1:415 W 33RD ST
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-3460
Practice Address - Country:US
Practice Address - Phone:308-236-7545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE423101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025506300Medicaid