Provider Demographics
NPI:1609133461
Name:PRASERTKUL, TIFFANY ANN (LMSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:PRASERTKUL
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 1:975 FOOTHILLS ROAD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29617
Mailing Address - Country:US
Mailing Address - Phone:864-371-1274
Mailing Address - Fax:
Practice Address - Street 1:975 FOOTHILLS ROAD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29617
Practice Address - Country:US
Practice Address - Phone:864-371-1274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC91241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical