Provider Demographics
NPI:1548617129
Name:MENNELLA, TIFFANY (LMSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MENNELLA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3380 NOSTRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-4056
Mailing Address - Country:US
Mailing Address - Phone:917-933-4545
Mailing Address - Fax:718-764-1165
Practice Address - Street 1:3380 NOSTRAND AVE
Practice Address - Street 2:SUITE 1E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4056
Practice Address - Country:US
Practice Address - Phone:917-933-4545
Practice Address - Fax:718-764-1165
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093466104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker