Provider Demographics
NPI:1124102827
Name:KAVANAUGH, TIFFANY M (LCSW)
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:M
Last Name:KAVANAUGH
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 1:3701 UNION DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-6629
Mailing Address - Country:US
Mailing Address - Phone:402-875-9270
Mailing Address - Fax:
Practice Address - Street 1:3701 UNION DR STE 100
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-6629
Practice Address - Country:US
Practice Address - Phone:402-875-9270
Practice Address - Fax:402-875-9272
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE278094Medicare ID - Type Unspecified