Provider Demographics
NPI:1356517858
Name:PROFESSIONAL MENTAL HEALTH SERVICES, L.L.C.
Entity type:Organization
Organization Name:PROFESSIONAL MENTAL HEALTH SERVICES, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOLAINE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:402-562-7099
Mailing Address - Street 1:5 ROBIN LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68601-6200
Mailing Address - Country:US
Mailing Address - Phone:402-562-7099
Mailing Address - Fax:
Practice Address - Street 1:3314 26TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-2304
Practice Address - Country:US
Practice Address - Phone:402-562-7099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1541101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025626600Medicaid
NE274000Medicare UPIN