Basic Information
| Provider Information | |||||||||
| NPI: | 1548285638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 985450 NEBRASKA MED CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681985450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025595756 | ||||||||
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| Practice Location | |||||||||
| Address1: | 444 S 44TH ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681313727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025596408 | ||||||||
| FaxNumber: | 4025595737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 245 | NE | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | 245 | NE | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 100252872 | 05 | NE | MEDICAID |