Healthcare Provider Details

I. General information

NPI: 1598095374
Provider Name (Legal Business Name): SAMANTHA JUNE ACOSTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2009
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12001 Q ST
OMAHA NE
68137-3542
US

IV. Provider business mailing address

PO BOX 391124
OMAHA NE
68139-1124
US

V. Phone/Fax

Practice location:
  • Phone: 402-592-0328
  • Fax:
Mailing address:
  • Phone: 435-238-0331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number7967230-3904
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: