Basic Information
Provider Information
NPI: 1003002981
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KIMMERLING
FirstName: KATHERINE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: LIMHP, LADC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: HRUSKA
OtherFirstName: KATHERINE
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: LIMHP, LADC
OtherLastNameType: 1
Mailing Information
Address1: 730 FORT CROOK RD N
Address2:  
City: BELLEVUE
State: NE
PostalCode: 680054558
CountryCode: US
TelephoneNumber: 4026613131
FaxNumber: 4022920342
Practice Location
Address1: 730 FORT CROOK RD N
Address2:  
City: BELLEVUE
State: NE
PostalCode: 680054558
CountryCode: US
TelephoneNumber: 4022929105
FaxNumber: 4022920342
Other Information
ProviderEnumerationDate: 09/24/2007
LastUpdateDate: 06/27/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000X3049NEY Behavioral Health & Social Service ProvidersCounselor 

ID Information
IDTypeStateIssuerDescription
4703766063105NE MEDICAID


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