Basic Information
| Provider Information | |||||||||
| NPI: | 1861665614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NESIBA | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | LEA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCGRATH | ||||||||
| OtherFirstName: | CYNTHIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1077 CHAMBERS ST | ||||||||
| Address2: | STE 2 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974023706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413428437 | ||||||||
| FaxNumber: | 4582017150 | ||||||||
| Practice Location | |||||||||
| Address1: | 1077 CHAMBERS ST | ||||||||
| Address2: | STE 2 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974023706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029843004 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2008 | ||||||||
| LastUpdateDate: | 05/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 3529 | NE | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | L6819 | OR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 1321 | NE | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | L6819 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | 8102 | NE | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 10025173100 | 05 | NE | MEDICAID |