Provider Demographics
NPI:1730886037
Name:FIRESIDE LLC
Entity type:Organization
Organization Name:FIRESIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ARYNNE
Authorized Official - Middle Name:
Authorized Official - Last Name:HORTON
Authorized Official - Suffix:
Authorized Official - Credentials:LP
Authorized Official - Phone:785-580-3937
Mailing Address - Street 1:1011 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BEATRICE
Mailing Address - State:NE
Mailing Address - Zip Code:68310-2356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BEATRICE
Practice Address - State:NE
Practice Address - Zip Code:68310-2356
Practice Address - Country:US
Practice Address - Phone:785-580-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025287200Medicaid