Healthcare Provider Details

I. General information

NPI: 1558524660
Provider Name (Legal Business Name): TIFFANY M KAVANAUGH LCSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 05/09/2023
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 UNION DR SUITE 206
LINCOLN NE
68516-6652
US

IV. Provider business mailing address

3701 UNION DR STE 100
LINCOLN NE
68516-6629
US

V. Phone/Fax

Practice location:
  • Phone: 402-489-2218
  • Fax:
Mailing address:
  • Phone: 402-875-9270
  • Fax: 402-875-9272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number424
License Number StateNE

VIII. Authorized Official

Name: TIFFANY M KAVANAUGH
Title or Position: SOLE MEMBER/MANAGER
Credential: LCSW
Phone: 25-404-9534