Provider Demographics
NPI:1710254933
Name:SMITH, TIFFANY (BSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12552 US HIGHWAY 61
Mailing Address - Street 2:
Mailing Address - City:FENNIMORE
Mailing Address - State:WI
Mailing Address - Zip Code:53809-9613
Mailing Address - Country:US
Mailing Address - Phone:608-732-3710
Mailing Address - Fax:
Practice Address - Street 1:1407 SAINT ANDREW ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-3301
Practice Address - Country:US
Practice Address - Phone:608-785-6266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10891-120171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator