Organization
PINE LAKE BEHAVIORAL HEALTH, LLC.
Active
Organization
PINE LAKE BEHAVIORAL HEALTH, LLC.
Active
Other names
Pine Lake Behavioral Health
Organization subpart
No
Provider details
NPI number
Authorized official
JARED WADE RAY LIPC, LADC (DIRECTOR OF OPERATIONS)
(402) 434-2730
Entity
Organization
Contact information
Practice address
9100 ANDERMATT DRIVE SUITE 1, LINCOLN, NE 68526-0000
(402) 434-2730
(402) 434-3970
Mailing address
9100 ANDERMATT DR STE 1, LINCOLN, NE 68526-6700
(402) 434-2730
(402) 434-3970
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
NE
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
—
—
333600000X
Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
10026721200
—
NE
05
—
10026721201
—
NE
01
—
DY5949
RR MEDICARE PTAN
NE
01
—
NA3283
MEDICARE PTAN
NE
Enumeration date
03/22/2018
Last updated
02/24/2020
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