Basic Information
| Provider Information | |||||||||
| NPI: | 1861714040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAUN | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LADC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIRKWOOD | ||||||||
| OtherFirstName: | DIANE | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 124 S. 24TH ST | ||||||||
| Address2: | STE 230 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681021226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029785673 | ||||||||
| FaxNumber: | 5015915075 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 LAKE ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681103866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024559757 | ||||||||
| FaxNumber: | 4025915075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2010 | ||||||||
| LastUpdateDate: | 06/17/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 9066 | NE | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | 1017 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.