Healthcare Provider Details

I. General information

NPI: 1467112417
Provider Name (Legal Business Name): TIFFANY NICOLE SHURTZ MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2021
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 GAS PLANT RD
DU QUIN IL
62832-3866
US

IV. Provider business mailing address

PO BOX 155
CHRISTOPHER IL
62822-0155
US

V. Phone/Fax

Practice location:
  • Phone: 618-790-2146
  • Fax: 618-790-2147
Mailing address:
  • Phone: 618-724-1633
  • Fax: 618-724-4628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149023877
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: