Provider Demographics
NPI:1124399464
Name:FAMILY NETWORK
Entity type:Organization
Organization Name:FAMILY NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:MINDT LONG
Authorized Official - Suffix:
Authorized Official - Credentials:LIMHP, LCSW
Authorized Official - Phone:308-382-8085
Mailing Address - Street 1:1811 W 2ND ST
Mailing Address - Street 2:SUITE 330
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-5413
Mailing Address - Country:US
Mailing Address - Phone:308-382-8085
Mailing Address - Fax:308-382-2582
Practice Address - Street 1:1811 W 2ND ST
Practice Address - Street 2:SUITE 330
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-5413
Practice Address - Country:US
Practice Address - Phone:308-382-8085
Practice Address - Fax:308-382-2582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE320,787, AND 511101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026098900Medicaid
NE260662OtherPTAN MDCR (ORIGINAL)