Provider Demographics
NPI:1962861724
Name:KOSIBA, EMMILIE
Entity Type:Individual
Prefix:
First Name:EMMILIE
Middle Name:
Last Name:KOSIBA
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 1:3925 S 147TH ST STE 109-111
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5565
Mailing Address - Country:US
Mailing Address - Phone:402-942-1329
Mailing Address - Fax:
Practice Address - Street 1:8525 EXECUTIVE WOODS DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68512-9300
Practice Address - Country:US
Practice Address - Phone:402-942-1329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2021-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NE2513225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst