Provider Demographics
NPI:1134490477
Name:TIFFANY, KARL SCOTT (LCPC)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:SCOTT
Last Name:TIFFANY
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:SCOTT
Other - Middle Name:
Other - Last Name:TIFFANY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCPC
Mailing Address - Street 1:2726 N LAPIS AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1559
Mailing Address - Country:US
Mailing Address - Phone:480-250-4603
Mailing Address - Fax:
Practice Address - Street 1:6550 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8780
Practice Address - Country:US
Practice Address - Phone:208-342-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10-R-31101YA0400X
ORC2797101YP2500X
IDLCPC5257101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional