Provider Demographics
NPI:1790799336
Name:PETERSEN, TIFFANIE ANN (MSW, PLMHP)
Entity Type:Individual
Prefix:MS
First Name:TIFFANIE
Middle Name:ANN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MSW, PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 S 139TH CT APT 20
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-2311
Mailing Address - Country:US
Mailing Address - Phone:402-917-7217
Mailing Address - Fax:
Practice Address - Street 1:2833 S 87TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-3046
Practice Address - Country:US
Practice Address - Phone:402-398-9852
Practice Address - Fax:402-398-9852
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEPLMHP 7471, MSW 63961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical