Healthcare Provider Details

I. General information

NPI: 1447621602
Provider Name (Legal Business Name): TIFFANY SMALLS-WILSON LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 TILDEN ST
BRONX NY
10467-6013
US

IV. Provider business mailing address

750 TILDEN ST
BRONX NY
10467-6013
US

V. Phone/Fax

Practice location:
  • Phone: 718-231-3400
  • Fax: 718-655-3503
Mailing address:
  • Phone: 718-231-3400
  • Fax: 718-655-3503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001167
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: