Provider Demographics
NPI:1508646928
Name:LOVELACE, TIFFANY ANN (LMSW, ACSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:LOVELACE
Suffix:
Gender:F
Credentials:LMSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2184 CHANNING WAY # 134
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8034
Mailing Address - Country:US
Mailing Address - Phone:209-996-4078
Mailing Address - Fax:
Practice Address - Street 1:285 POKER FLAT RD
Practice Address - Street 2:
Practice Address - City:COPPEROPOLIS
Practice Address - State:CA
Practice Address - Zip Code:95228-9610
Practice Address - Country:US
Practice Address - Phone:209-996-4078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111230104100000X
CA118172104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker