Provider Demographics
NPI:1336308709
Name:TIFFANY, MATTHEW (LCPC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:TIFFANY
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2031
Mailing Address - Country:US
Mailing Address - Phone:207-518-8145
Mailing Address - Fax:
Practice Address - Street 1:11 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2690
Practice Address - Country:US
Practice Address - Phone:207-373-9417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC3955101YM0800X, 101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health