Basic Information
| Provider Information | |||||||||
| NPI: | 1104922699 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASSARA | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LIMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 S 24TH ST | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681021226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029785656 | ||||||||
| FaxNumber: | 4025915075 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 FORT CROOK RD N | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680054558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4022929105 | ||||||||
| FaxNumber: | 4022920342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 10/23/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 1838 | NE | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | 291 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 23726797201 | 05 | NE | MEDICAID |