Provider Demographics
NPI:1467192419
Name:SEVILLA LUZURIAGA, FABIAN EDUARDO (PLMHP 12897)
Entity Type:Individual
Prefix:MR
First Name:FABIAN
Middle Name:EDUARDO
Last Name:SEVILLA LUZURIAGA
Suffix:
Gender:M
Credentials:PLMHP 12897
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2912 KIMLER AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-3312
Mailing Address - Country:US
Mailing Address - Phone:308-233-7767
Mailing Address - Fax:
Practice Address - Street 1:2002 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-5302
Practice Address - Country:US
Practice Address - Phone:308-627-6119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12897101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health