Provider Demographics
NPI:1073652111
Name:BACON, KATIE LEE (MA MASTER OF ARTS)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LEE
Last Name:BACON
Suffix:
Gender:F
Credentials:MA MASTER OF ARTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7501 O ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2485
Mailing Address - Country:US
Mailing Address - Phone:402-477-0651
Mailing Address - Fax:402-477-0332
Practice Address - Street 1:7501 O ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2485
Practice Address - Country:US
Practice Address - Phone:402-477-0651
Practice Address - Fax:402-477-0332
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1721101YP2500X
NE3399101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE96065OtherBCBS