Provider Demographics
NPI:1235705989
Name:GLISSON, TIFFANY LYNETTE (LCSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNETTE
Last Name:GLISSON
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 1:3436 SPRING CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7169
Mailing Address - Country:US
Mailing Address - Phone:843-224-2673
Mailing Address - Fax:
Practice Address - Street 1:3436 SPRING CREEK DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7169
Practice Address - Country:US
Practice Address - Phone:843-224-2673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0068621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical