Healthcare Provider Details

I. General information

NPI: 1801358460
Provider Name (Legal Business Name): CHARISSA DAGEFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHARISSA TVRDY

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 VICTORY PARK DR
LINCOLN NE
68510-2484
US

IV. Provider business mailing address

420 VICTORY PARK DR
LINCOLN NE
68510-2484
US

V. Phone/Fax

Practice location:
  • Phone: 402-489-3802
  • Fax:
Mailing address:
  • Phone: 402-489-3802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1205
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: