Provider Demographics
NPI:1417614280
Name:MICKENS, TIFFANY (LCSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MICKENS
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 1:762 CREEK BOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-6665
Mailing Address - Country:US
Mailing Address - Phone:347-575-3084
Mailing Address - Fax:
Practice Address - Street 1:24230 KARIM BLVD STE 100
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2960
Practice Address - Country:US
Practice Address - Phone:248-745-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0880951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical