Provider Demographics
NPI:1356822423
Name:MITWARUCIU, ALICE N (PHD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:N
Last Name:MITWARUCIU
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 CORNHUSKER HWY
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68507-3175
Mailing Address - Country:US
Mailing Address - Phone:402-421-1182
Mailing Address - Fax:402-465-8717
Practice Address - Street 1:620 N 48TH ST STE 202
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68504-3466
Practice Address - Country:US
Practice Address - Phone:402-489-6196
Practice Address - Fax:402-465-8717
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE841103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE$$$$$$$$$02Medicaid