Provider Demographics
NPI:1629146337
Name:KOENEN, TIFFANY DAWN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:DAWN
Last Name:KOENEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9647 DEERHORN CT APT 151
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-3140
Mailing Address - Country:US
Mailing Address - Phone:720-626-5758
Mailing Address - Fax:
Practice Address - Street 1:6551 S REVERE PKWY STE 255
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80111-6471
Practice Address - Country:US
Practice Address - Phone:720-735-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW-000017911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025455400Medicaid