Healthcare Provider Details

I. General information

NPI: 1467192419
Provider Name (Legal Business Name): FABIAN EDUARDO SEVILLA LUZURIAGA LMHP 6352
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2608 OLD FAIR RD
GRAND ISLAND NE
68803-5271
US

IV. Provider business mailing address

2608 OLD FAIR RD
GRAND ISLAND NE
68803-5271
US

V. Phone/Fax

Practice location:
  • Phone: 308-382-5297
  • Fax: 308-382-5315
Mailing address:
  • Phone: 308-382-5297
  • Fax: 308-382-5315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6352
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: