Provider Demographics
NPI:1942848593
Name:SPECIALIZED OUTPATIENT SERVICES
Entity Type:Organization
Organization Name:SPECIALIZED OUTPATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH PRACTIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KISSACK
Authorized Official - Suffix:
Authorized Official - Credentials:LIMHP
Authorized Official - Phone:308-379-8619
Mailing Address - Street 1:1811 WEST 2ND STREET SUITE 450
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803
Mailing Address - Country:US
Mailing Address - Phone:308-379-8619
Mailing Address - Fax:308-384-0194
Practice Address - Street 1:1811 WEST 2ND STREET SUITE 450
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803
Practice Address - Country:US
Practice Address - Phone:308-379-8619
Practice Address - Fax:308-384-0194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty