Provider Demographics
NPI:1689947632
Name:NOEL, TIFFANY KATHLEEN (MA LCPC)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:KATHLEEN
Last Name:NOEL
Suffix:
Gender:F
Credentials:MA LCPC
Other - Prefix:MRS
Other - First Name:TIFFANY
Other - Middle Name:KATHLEEN
Other - Last Name:RUSK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:530 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61637-0001
Mailing Address - Country:US
Mailing Address - Phone:309-624-9522
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-624-9522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007395101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional