Healthcare Provider Details

I. General information

NPI: 1992592372
Provider Name (Legal Business Name): TIFFANY WREN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 LEFEBVRE WAY
ANTIOCH CA
94531-8119
US

IV. Provider business mailing address

PO BOX 3602
ANTIOCH CA
94531-3602
US

V. Phone/Fax

Practice location:
  • Phone: 510-381-9696
  • Fax:
Mailing address:
  • Phone: 510-381-9696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number127431
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: