Healthcare Provider Details

I. General information

NPI: 1710254933
Provider Name (Legal Business Name): TIFFANY SMITH BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 SAINT ANDREW ST SUITE 100
LA CROSSE WI
54603-3301
US

IV. Provider business mailing address

12552 US HIGHWAY 61
FENNIMORE WI
53809-9613
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-6266
  • Fax:
Mailing address:
  • Phone: 608-732-3710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number10891-120
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: