Provider Demographics
NPI:1225182520
Name:BLANKENAU, LISA RENEE (PHD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:RENEE
Last Name:BLANKENAU
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5945 S 56TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-3394
Mailing Address - Country:US
Mailing Address - Phone:402-423-9303
Mailing Address - Fax:402-423-5662
Practice Address - Street 1:5945 S 56TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-3394
Practice Address - Country:US
Practice Address - Phone:402-423-9303
Practice Address - Fax:402-423-5662
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE437103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100251111-00Medicaid