Healthcare Provider Details

I. General information

NPI: 1144702440
Provider Name (Legal Business Name): TIFANIE ANN KUKWA LPCC-SUPV, LICDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W 3RD ST
DOVER OH
44622-2934
US

IV. Provider business mailing address

130 W 3RD ST
DOVER OH
44622-2934
US

V. Phone/Fax

Practice location:
  • Phone: 330-343-6600
  • Fax: 330-343-6600
Mailing address:
  • Phone: 330-343-6600
  • Fax: 330-343-6405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberE1800986
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC161884
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.1800986-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: