Provider Demographics
NPI:1396616512
Name:KOALA, TEGAWENDE
Entity type:Individual
Prefix:
First Name:TEGAWENDE
Middle Name:
Last Name:KOALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11107 COTTONWOOD PLZ
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-3732
Mailing Address - Country:US
Mailing Address - Phone:602-616-8591
Mailing Address - Fax:
Practice Address - Street 1:1805 N 73RD ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-1905
Practice Address - Country:US
Practice Address - Phone:402-575-8583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-12
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities