Healthcare Provider Details

I. General information

NPI: 1013765205
Provider Name (Legal Business Name): TIFFANY GOTTERBARN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2024
Last Update Date: 05/11/2024
Certification Date: 05/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

998 OLD COUNTRY RD
PLAINVIEW NY
11803-4928
US

IV. Provider business mailing address

998 OLD COUNTRY RD
PLAINVIEW NY
11803-4928
US

V. Phone/Fax

Practice location:
  • Phone: 516-390-4347
  • Fax:
Mailing address:
  • Phone: 516-390-4347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number090198-01
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: