Provider Demographics
NPI:1679104343
Name:KILROY, TIFFANY RENATE (LMHC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:RENATE
Last Name:KILROY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 PLAZA DR., SUITE 2
Mailing Address - Street 2:PMB 279
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-1572
Mailing Address - Country:US
Mailing Address - Phone:219-230-8311
Mailing Address - Fax:
Practice Address - Street 1:55 SHORE DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-1008
Practice Address - Country:US
Practice Address - Phone:219-230-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003699A101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health