Provider Demographics
NPI:1790457307
Name:SMITH, TIFFANY (MS)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 N 43RD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-2721
Mailing Address - Country:US
Mailing Address - Phone:414-551-9444
Mailing Address - Fax:
Practice Address - Street 1:4550 W BRADLEY RD
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-3713
Practice Address - Country:US
Practice Address - Phone:414-371-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4365-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health