Healthcare Provider Details

I. General information

NPI: 1205698776
Provider Name (Legal Business Name): TIFFANIE CRUZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

234 WEXFORD WAY
CLARKSVILLE TN
37042-8956
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8400
  • Fax:
Mailing address:
  • Phone: 931-378-4333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC020678
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: