Provider Demographics
NPI:1750632451
Name:SMITH, TIFFANY ROSALIND (LCSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ROSALIND
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 GRAND AVE STE D
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95838-3466
Mailing Address - Country:US
Mailing Address - Phone:916-922-9868
Mailing Address - Fax:916-922-7342
Practice Address - Street 1:670 PLACERVILLE DR # 2
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-4200
Practice Address - Country:US
Practice Address - Phone:530-644-2412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-21
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA167G00000X390200000X
CA952181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program