Provider Demographics
NPI:1871514539
Name:MALLETT, TERESA LYNN (MS, LIMHP)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:MALLETT
Suffix:
Gender:F
Credentials:MS, LIMHP
Other - Prefix:
Other - First Name:RESA
Other - Middle Name:LYNN
Other - Last Name:MALLETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LIMHP
Mailing Address - Street 1:13504 STEVENS ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-1634
Mailing Address - Country:US
Mailing Address - Phone:402-894-9805
Mailing Address - Fax:402-894-1015
Practice Address - Street 1:13504 STEVENS ST
Practice Address - Street 2:SUITE A
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1634
Practice Address - Country:US
Practice Address - Phone:402-894-9805
Practice Address - Fax:402-894-1015
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE194101YM0800X
NE84101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025687200Medicaid