Provider Demographics
NPI:1760668768
Name:KANESVILLE THERAPY LLC
Entity Type:Organization
Organization Name:KANESVILLE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ANDERSEN BURGHER
Authorized Official - Suffix:
Authorized Official - Credentials:MS LMHC LMHP LIMHP
Authorized Official - Phone:712-328-9205
Mailing Address - Street 1:16 LOCUST LODGE
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503
Mailing Address - Country:US
Mailing Address - Phone:712-328-9205
Mailing Address - Fax:
Practice Address - Street 1:35 MAIN PLACE
Practice Address - Street 2:SUITE 100 OMNI CENTER BUSINESS PARK
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503
Practice Address - Country:US
Practice Address - Phone:712-328-9205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-21
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00169101YM0800X
NE1750101YM0800X
NE376101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty