Healthcare Provider Details

I. General information

NPI: 1841125234
Provider Name (Legal Business Name): KYRA TIFFANY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 ROGERS DR STE 200
ROGERS MN
55374-4926
US

IV. Provider business mailing address

21000 ROGERS DR STE 200
ROGERS MN
55374-4926
US

V. Phone/Fax

Practice location:
  • Phone: 763-291-5505
  • Fax:
Mailing address:
  • Phone: 612-412-4160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number28447
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: