Provider Demographics
NPI:1114107455
Name:GRANT, TIFFANY S (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:S
Last Name:GRANT
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 1:21 BREEZY HILL DR
Mailing Address - Street 2:
Mailing Address - City:FORT SALONGA
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2614
Mailing Address - Country:US
Mailing Address - Phone:516-729-9859
Mailing Address - Fax:631-414-7091
Practice Address - Street 1:79 MIDDLEVILLE RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2200
Practice Address - Country:US
Practice Address - Phone:631-707-6507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-03
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075989-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical