Provider Demographics
NPI:1174665871
Name:LUEBBERT, MARY T
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:LUEBBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 LYNCREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510
Mailing Address - Country:US
Mailing Address - Phone:402-434-3370
Mailing Address - Fax:402-489-0731
Practice Address - Street 1:220 LYNCREST DRIVE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510
Practice Address - Country:US
Practice Address - Phone:402-434-3370
Practice Address - Fax:402-489-0731
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE498133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q58513Medicare UPIN
279575Medicare ID - Type Unspecified