Provider Demographics
NPI:1144646142
Name:PRAIRIE PSYCHOLOGICAL SERVICES, INC
Entity type:Organization
Organization Name:PRAIRIE PSYCHOLOGICAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TWILA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PRESTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:402-494-0040
Mailing Address - Street 1:625 E 39TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH SIOUX CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68776-3445
Mailing Address - Country:US
Mailing Address - Phone:402-494-0040
Mailing Address - Fax:
Practice Address - Street 1:219 MAIN ST
Practice Address - Street 2:STE 2
Practice Address - City:WAYNE
Practice Address - State:NE
Practice Address - Zip Code:68787-1924
Practice Address - Country:US
Practice Address - Phone:402-494-0040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRAIRIE PSYCHOLOGICAL SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE531103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE293374000Medicaid
NE278725Medicare UPIN