Provider Demographics
NPI:1639580715
Name:ROOT, TIFFANY LYNN (LPC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNN
Last Name:ROOT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2578 SYLVAN SHORES DR.
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:UNITED STATES
Mailing Address - Zip Code:48328
Mailing Address - Country:UM
Mailing Address - Phone:989-284-4556
Mailing Address - Fax:
Practice Address - Street 1:17421 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3165
Practice Address - Country:US
Practice Address - Phone:989-790-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013988101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional