Healthcare Provider Details

I. General information

NPI: 1417628736
Provider Name (Legal Business Name): TIFFANY BERNARD LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 09/27/2021
Certification Date: 09/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N MICHIGAN AVE STE 1400
CHICAGO IL
60601-4011
US

IV. Provider business mailing address

5136 S KIMBARK AVE
CHICAGO IL
60615-3834
US

V. Phone/Fax

Practice location:
  • Phone: 312-815-9660
  • Fax:
Mailing address:
  • Phone: 773-822-1719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.010027
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: