Provider Demographics
NPI:1558908277
Name:KALICK, TIFFANY KRISTEN (LEP)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:KRISTEN
Last Name:KALICK
Suffix:
Gender:F
Credentials:LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 EL CAMINO REAL STE E
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-2110
Mailing Address - Country:US
Mailing Address - Phone:760-845-5803
Mailing Address - Fax:
Practice Address - Street 1:3150 EL CAMINO REAL STE E
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2110
Practice Address - Country:US
Practice Address - Phone:760-845-5803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-01
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEP3544103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA83-1608338OtherN/A