Healthcare Provider Details

I. General information

NPI: 1083075006
Provider Name (Legal Business Name): TIFFANY SAMUELSON LMSW, CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2016
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 NEBRASKA ST
SIOUX CITY IA
51105-1436
US

IV. Provider business mailing address

3320 W 4TH ST
SIOUX CITY IA
51103-3200
US

V. Phone/Fax

Practice location:
  • Phone: 122-522-4777
  • Fax: 712-252-5920
Mailing address:
  • Phone: 712-202-0777
  • Fax: 712-234-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13042
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number073276
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: