Healthcare Provider Details

I. General information

NPI: 1487985339
Provider Name (Legal Business Name): MARIE TIFFANY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 02/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 SOUTH ST. 1 ST FLOOR
PITTSFIELD MA
01201-4714
US

IV. Provider business mailing address

877 SOUTH ST. 1 ST FLOOR
PITTSFIELD MA
01201-4714
US

V. Phone/Fax

Practice location:
  • Phone: 413-236-5656
  • Fax: 413-499-6572
Mailing address:
  • Phone: 413-236-5656
  • Fax: 413-499-6572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number218092
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: