Provider Demographics
NPI:1104922699
Name:MASSARA, KIMBERLY A (LIMHP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:MASSARA
Suffix:
Gender:F
Credentials:LIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 S 24TH ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-1226
Mailing Address - Country:US
Mailing Address - Phone:402-978-5656
Mailing Address - Fax:402-591-5075
Practice Address - Street 1:730 FORT CROOK RD N
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-4558
Practice Address - Country:US
Practice Address - Phone:402-292-9105
Practice Address - Fax:402-292-0342
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1838106H00000X
NE291101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE23726797201Medicaid