Provider Demographics
NPI:1124760822
Name:OLGUIN, MAURITA
Entity type:Individual
Prefix:
First Name:MAURITA
Middle Name:
Last Name:OLGUIN
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 1:910 AVENUE F
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-2060
Mailing Address - Country:US
Mailing Address - Phone:308-537-4332
Mailing Address - Fax:308-382-9255
Practice Address - Street 1:910 AVENUE F
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-2060
Practice Address - Country:US
Practice Address - Phone:308-537-4332
Practice Address - Fax:308-382-9255
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NECPSS-129175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NECPSS-129OtherSTATE OF NEBRASKA DIVISION OF BEHAVIORAL HEALTH