=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861708786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN MARIE TIFFANY LICSW, LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2010
-----------------------------------------------------
Last Update Date | 04/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 151 STAGECOACH TRL STE 220
-----------------------------------------------------
City | SAN MARCOS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78666-3863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 737-277-4221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2627 MARTIN WAY E STE 5
-----------------------------------------------------
City | OLYMPIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98506-4926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-830-6679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 115511
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LW60869700
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------