Provider Demographics
NPI:1689047110
Name:EVANS, TIFFANY M (LMSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:M
Last Name:EVANS
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 1:790 FULLER AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1918
Mailing Address - Country:US
Mailing Address - Phone:616-336-3909
Mailing Address - Fax:616-336-8830
Practice Address - Street 1:790 FULLER AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1918
Practice Address - Country:US
Practice Address - Phone:616-336-3909
Practice Address - Fax:616-336-8830
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI68011155741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)