Provider Demographics
NPI:1952090730
Name:SUGIURA, MARIAH LYNN (LSC)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:LYNN
Last Name:SUGIURA
Suffix:
Gender:F
Credentials:LSC
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:LYNN
Other - Last Name:ACOSTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11001 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-5085
Mailing Address - Country:US
Mailing Address - Phone:808-321-9963
Mailing Address - Fax:
Practice Address - Street 1:14710 W DODGE RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-2027
Practice Address - Country:US
Practice Address - Phone:402-709-8338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2019010207101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool