Provider Demographics
NPI:1760680409
Name:TIFFANY D. KOENEN, LCSW, P.C.
Entity Type:Organization
Organization Name:TIFFANY D. KOENEN, LCSW, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:KOENEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:402-502-1024
Mailing Address - Street 1:8021 CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3533
Mailing Address - Country:US
Mailing Address - Phone:402-502-1024
Mailing Address - Fax:402-502-1555
Practice Address - Street 1:8021 CHICAGO ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3533
Practice Address - Country:US
Practice Address - Phone:402-502-1024
Practice Address - Fax:402-502-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1028251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025455400Medicaid