Provider Demographics
NPI:1366092157
Name:ELLENBERGER, KIMBERLY (PLMHP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ELLENBERGER
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:ELLENBERGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PLMHP
Mailing Address - Street 1:4819 N 37TH ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-9203
Mailing Address - Country:US
Mailing Address - Phone:402-841-5376
Mailing Address - Fax:
Practice Address - Street 1:200 N 34TH ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-3197
Practice Address - Country:US
Practice Address - Phone:402-371-3044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11999101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health