Healthcare Provider Details

I. General information

NPI: 1508435934
Provider Name (Legal Business Name): TIFFANY LASHAWN KEITH MAFT ASSOCIATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 DAVENTRY LN STE 5
LOUISVILLE KY
40223-2869
US

IV. Provider business mailing address

201 KEWANNA DR
JEFFERSONVILLE IN
47130-4805
US

V. Phone/Fax

Practice location:
  • Phone: 502-817-8229
  • Fax:
Mailing address:
  • Phone: 812-920-0194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number270845
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: