Provider Demographics
NPI:1508533498
Name:NISWONGER, TIFFANY DULAMAL (LCSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DULAMAL
Last Name:NISWONGER
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 1:6705 WILD FOX LN
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9479
Mailing Address - Country:US
Mailing Address - Phone:912-484-2858
Mailing Address - Fax:
Practice Address - Street 1:1904 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1452
Practice Address - Country:US
Practice Address - Phone:502-694-9488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2552561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical