Provider Demographics
NPI:1619424769
Name:CRAIN, TIFFANY MARIE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:CRAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-9020
Mailing Address - Country:US
Mailing Address - Phone:425-345-0579
Mailing Address - Fax:
Practice Address - Street 1:3322 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4425
Practice Address - Country:US
Practice Address - Phone:425-345-0579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00005637101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)