Basic Information
| Provider Information | |||||||||
| NPI: | 1215029681 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAYNE | ||||||||
| FirstName: | ROXANNE | ||||||||
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| Credential: | LMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 S 24TH ST | ||||||||
| Address2: | STE 230 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681021226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029785656 | ||||||||
| FaxNumber: | 4025915075 | ||||||||
| Practice Location | |||||||||
| Address1: | 7110 F ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681171014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025951073 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2854 | NE | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 10024954800 | 05 | NE | MEDICAID |