Provider Demographics
NPI:1073119954
Name:MARTIN, TIFFANY MAY (LCSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MAY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5532 ASHLEIGH RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-7243
Mailing Address - Country:US
Mailing Address - Phone:541-908-1572
Mailing Address - Fax:
Practice Address - Street 1:5532 ASHLEIGH RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7243
Practice Address - Country:US
Practice Address - Phone:541-908-1572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040106621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical