Healthcare Provider Details

I. General information

NPI: 1285953604
Provider Name (Legal Business Name): TIFFANY SHAWN MCLALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 05/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 STONE ST 2 FLOOR
WATERTOWN NY
13601-3211
US

IV. Provider business mailing address

218 STONE ST 2 FLOOR
WATERTOWN NY
13601-3211
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-7445
  • Fax: 315-779-1184
Mailing address:
  • Phone: 315-782-7445
  • Fax: 315-779-1184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP75075
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: