Provider Demographics
NPI:1801091988
Name:PEDIATRIC PSYCHOLOGY ASSOCIATES, PC
Entity type:Organization
Organization Name:PEDIATRIC PSYCHOLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LELAND
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:ZLOMKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:402-806-1700
Mailing Address - Street 1:1400 OAK STREET
Mailing Address - Street 2:
Mailing Address - City:BEATRICE
Mailing Address - State:NE
Mailing Address - Zip Code:68310-4402
Mailing Address - Country:US
Mailing Address - Phone:402-806-1700
Mailing Address - Fax:402-228-2202
Practice Address - Street 1:722 COURT ST STE 103
Practice Address - Street 2:
Practice Address - City:BEATRICE
Practice Address - State:NE
Practice Address - Zip Code:68310-3928
Practice Address - Country:US
Practice Address - Phone:402-806-1700
Practice Address - Fax:402-228-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101Y00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100257225-00Medicaid
NE100257225-00Medicaid