Healthcare Provider Details

I. General information

NPI: 1942130638
Provider Name (Legal Business Name): LAVENDER ROAD THERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/23/2026
Certification Date: 05/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4611 S 96TH ST STE 174
OMAHA NE
68127-1242
US

IV. Provider business mailing address

4611 S 96TH ST STE 174
OMAHA NE
68127-1242
US

V. Phone/Fax

Practice location:
  • Phone: 402-320-2336
  • Fax:
Mailing address:
  • Phone: 402-320-2336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANGELA A KENEDY
Title or Position: THERAPIST/OWNER
Credential: LIMHP, LCSW, LADC
Phone: 402-320-2336