Healthcare Provider Details

I. General information

NPI: 1679315923
Provider Name (Legal Business Name): TIFFANY AUGUSTINE PSYD, LCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2024
Last Update Date: 06/08/2024
Certification Date: 06/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9407 CUMBERLAND RD
NEW KENT VA
23124-2029
US

IV. Provider business mailing address

150 KINGS MANOR DR APT 9134
WILLIAMSBURG VA
23185-3081
US

V. Phone/Fax

Practice location:
  • Phone: 804-966-2242
  • Fax:
Mailing address:
  • Phone: 337-224-2151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810008525
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: