Provider Demographics
NPI:1639541345
Name:GENTLESS, TIFFANIE (MENTAL HEALTH CLINIC)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANIE
Middle Name:
Last Name:GENTLESS
Suffix:
Gender:F
Credentials:MENTAL HEALTH CLINIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6143 186TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2710
Mailing Address - Country:US
Mailing Address - Phone:347-506-3986
Mailing Address - Fax:
Practice Address - Street 1:6143 186TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-2710
Practice Address - Country:US
Practice Address - Phone:347-506-3986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP99221101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health