1912103185 NPI number — TIFFANY DAWN HOLTHUS LCSW

Table of content: (NPI 1760695878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912103185 NPI number — TIFFANY DAWN HOLTHUS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLTHUS
Provider First Name:
TIFFANY
Provider Middle Name:
DAWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ZERGER
Provider Other First Name:
TIFFANY
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912103185
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2309
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWTON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73502-2309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-357-9984
Provider Business Mailing Address Fax Number:
580-357-3277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5404 SW LEE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWTON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73505-9695
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-355-5242
Provider Business Practice Location Address Fax Number:
580-355-5245
Provider Enumeration Date:
06/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  6345 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 5288 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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