Provider Demographics
NPI:1790557205
Name:TIFFIN, MARY (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:TIFFIN
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:17889-9169
Mailing Address - Country:US
Mailing Address - Phone:570-716-0669
Mailing Address - Fax:
Practice Address - Street 1:298 E 5TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-2353
Practice Address - Country:US
Practice Address - Phone:570-317-2999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-27
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW129995104100000X
PACW0243411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker