Healthcare Provider Details

I. General information

NPI: 1750632451
Provider Name (Legal Business Name): TIFFANY ROSALIND SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 PLACERVILLE DR # 2
PLACERVILLE CA
95667-4200
US

IV. Provider business mailing address

811 GRAND AVE STE D
SACRAMENTO CA
95838-3466
US

V. Phone/Fax

Practice location:
  • Phone: 530-644-2412
  • Fax:
Mailing address:
  • Phone: 916-922-9868
  • Fax: 916-922-7342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number95218
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number167G00000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: