Healthcare Provider Details

I. General information

NPI: 1316109507
Provider Name (Legal Business Name): ANITA J TEUTSCH LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2008
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14020 LANCASHIRE ST APT 1
WAVERLY NE
68462-1160
US

IV. Provider business mailing address

PO BOX 135
EAGLE NE
68347-0135
US

V. Phone/Fax

Practice location:
  • Phone: 402-327-1390
  • Fax:
Mailing address:
  • Phone: 402-327-1390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number962
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: