Basic Information
Provider Information | |||||||||
NPI: | 1528692241 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZAGOZDA | ||||||||
FirstName: | HUONG | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LE | ||||||||
OtherFirstName: | HUONG | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2725 S 144TH ST STE 212 | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681445253 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4026370800 | ||||||||
FaxNumber: | 4026370808 | ||||||||
Practice Location | |||||||||
Address1: | 2725 S 144TH ST STE 212 | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681445253 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4026370800 | ||||||||
FaxNumber: | 4026370808 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/03/2020 | ||||||||
LastUpdateDate: | 08/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 114886 | IA | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225X00000X | 2368 | NE | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 50615242301 | 05 | NE |   | MEDICAID |