Provider Demographics
NPI:1689088452
Name:SHADLE-CUSIC, MARCIA (LMHP)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:SHADLE-CUSIC
Suffix:
Gender:F
Credentials:LMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8102 N 47TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68152-1904
Mailing Address - Country:US
Mailing Address - Phone:402-995-9158
Mailing Address - Fax:
Practice Address - Street 1:8102 N 47TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68152-1904
Practice Address - Country:US
Practice Address - Phone:402-995-9158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3172101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor