Provider Demographics
NPI:1598095374
Name:ACOSTA, SAMANTHA JUNE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JUNE
Last Name:ACOSTA
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:PO BOX 391124
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68139-1124
Mailing Address - Country:US
Mailing Address - Phone:435-238-0331
Mailing Address - Fax:
Practice Address - Street 1:12001 Q ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-3542
Practice Address - Country:US
Practice Address - Phone:402-592-0328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-30
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7967230-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1858OtherLIMHP