Provider Demographics
NPI:1376690891
Name:FARDELLA, TINA L (LMHP LCSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:L
Last Name:FARDELLA
Suffix:
Gender:F
Credentials:LMHP LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 COACHMANS DRIVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510
Mailing Address - Country:US
Mailing Address - Phone:402-483-5709
Mailing Address - Fax:
Practice Address - Street 1:5600 S 59TH ST STE 104
Practice Address - Street 2:ORR PSYCHOTHERAPY RESOURCES
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-2387
Practice Address - Country:US
Practice Address - Phone:402-484-0595
Practice Address - Fax:402-484-0595
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2525101YP2500X
NE10581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47084125026Medicaid
NE82697OtherBCBS
NE10024982600Medicaid
NE10024982600Medicaid