Healthcare Provider Details

I. General information

NPI: 1104807486
Provider Name (Legal Business Name): PHYLLIS TIFFANY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 MAIN ST SUITE 200
RICHFORD VT
05476-1153
US

IV. Provider business mailing address

207 CORLISS RD
RICHFORD VT
05476-1259
US

V. Phone/Fax

Practice location:
  • Phone: 802-255-5500
  • Fax: 802-255-5509
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0890000745
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: