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 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 3049 | NE | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 47037660631 | 05 | NE | MEDICAID |