Provider Demographics
NPI:1467199414
Name:ANDERSON, TIFFANY HARRISON (LICSW)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:HARRISON
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:TIFFANY
Other - Middle Name:LYN
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:52 RILEY RD # 206
Mailing Address - Street 2:
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-5420
Mailing Address - Country:US
Mailing Address - Phone:251-550-8789
Mailing Address - Fax:
Practice Address - Street 1:225 BELLA VERANO WAY
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-9508
Practice Address - Country:US
Practice Address - Phone:251-550-8789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5020C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical