Active NPI
Pine Lake Behavioral Health, LLC.
- Clinic/Center
- Lincoln, NE
National Provider Identifier
1003310061
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinic/Center
- Legal business name
- PINE LAKE BEHAVIORAL HEALTH, LLC.
- Practice address
- 9100 Andermatt Drive Suite 1
Lincoln, NE 68526-0000 - Phone
- (402) 434-2730
- Fax
- (402) 434-3970
- NPI assigned
- Mar 22, 2018
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Jared Wade Ray, LIPC, LADC
- Title
- Director of Operations
- Phone
- (402) 434-2730
Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinic/Center | 261Q00000X | NE | Primary | |
| Mental Health Clinic/Center (Including Community Mental Health Center) | 261QM0801X | |||
| Pharmacy | 333600000X |
Addresses
Primary practice location
9100 Andermatt Drive Suite 1
Lincoln, NE 68526-0000
Mailing address
9100 Andermatt Dr Ste 1
Lincoln, NE 68526-6700
Phone (402) 434-2730
Other identifiers 4
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 10026721200 | Medicaid | NE | |
| NA3283 | Other | NE | MEDICARE PTAN |
| 10026721201 | Medicaid | NE | |
| DY5949 | Other | NE | RR MEDICARE PTAN |
Other names 1
- Pine Lake Behavioral Health
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in NE
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20180418003008 | NE | Part B Supplier - Clinic/Group Practice | 7810250164 |
Receives reassigned benefits from 31 practitioners Practice locations: Lincoln, NE |
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 28D2077900 | Pine Lake Behavioral Health | Certificate of waiver | May 15, 2028 |
National Provider Directory
National Provider DirectoryLocations
9100 Andermatt Dr
Ste 1A
Lincoln, NE 68526
9100 Andermatt Dr
Lincoln, NE 68526
3901 Pine Lake Rd
Ste 410
Lincoln, NE 68516
Phone (402) 434-2730
Networks
- devoted network organization-4d06b5ed-aefa-4033-b81c-2adf126fd114
Practitioners & affiliated clinicians
Practitioners 40
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
-
- Psychiatric/Mental Health Nurse Practitioner
- Lincoln, NE
- NPI 1487078135
NE
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1521676800000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1582502400000",
"number": "1003310061",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "9100 ANDERMATT DR STE 1",
"city": "LINCOLN",
"state": "NE",
"postal_code": "685266700",
"telephone_number": "402-434-2730",
"fax_number": "402-434-3970"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "9100 ANDERMATT DRIVE SUITE 1",
"city": "LINCOLN",
"state": "NE",
"postal_code": "685260000",
"telephone_number": "402-434-2730",
"fax_number": "402-434-3970"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "PINE LAKE BEHAVIORAL HEALTH, LLC.",
"organizational_subpart": "NO",
"enumeration_date": "2018-03-22",
"last_updated": "2020-02-24",
"certification_date": "2020-02-24",
"status": "A",
"authorized_official_last_name": "RAY",
"authorized_official_first_name": "JARED",
"authorized_official_middle_name": "WADE",
"authorized_official_title_or_position": "DIRECTOR OF OPERATIONS",
"authorized_official_telephone_number": "402-434-2730",
"authorized_official_credential": "LIPC, LADC"
},
"taxonomies": [
{
"code": "261Q00000X",
"taxonomy_group": "",
"desc": "Clinic/Center",
"state": "NE",
"license": null,
"primary": true
},
{
"code": "261QM0801X",
"taxonomy_group": "",
"desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
"state": null,
"license": null,
"primary": false
},
{
"code": "333600000X",
"taxonomy_group": "",
"desc": "Pharmacy",
"state": null,
"license": null,
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "10026721200",
"state": "NE"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE PTAN",
"identifier": "NA3283",
"state": "NE"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "10026721201",
"state": "NE"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RR MEDICARE PTAN",
"identifier": "DY5949",
"state": "NE"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Pine Lake Behavioral Health",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "Pine Lake Behavioral Health",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Lincoln, NE
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 24, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.