Provider Demographics
NPI:1467568535
Name:SULLIVAN, TIFFANY NOEL EDMONDS (LCSW, JD)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:NOEL EDMONDS
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW, JD
Other - Prefix:MS
Other - First Name:TIFFANY
Other - Middle Name:NOEL
Other - Last Name:EDMONDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:205 HAMPTON HWY
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693
Mailing Address - Country:US
Mailing Address - Phone:757-865-1843
Mailing Address - Fax:
Practice Address - Street 1:205 HAMPTON HWY
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23693
Practice Address - Country:US
Practice Address - Phone:757-865-1843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040037821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8924287Medicaid