Provider Demographics
NPI:1932312733
Name:WOLLBERG, ANDY (LMHP, CPC)
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:WOLLBERG
Suffix:
Gender:M
Credentials:LMHP, CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 E 56TH ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-4179
Mailing Address - Country:US
Mailing Address - Phone:308-236-7145
Mailing Address - Fax:308-236-7150
Practice Address - Street 1:2041 E 56TH ST
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-4179
Practice Address - Country:US
Practice Address - Phone:308-236-7145
Practice Address - Fax:308-236-7150
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2375101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47079796127Medicaid