Provider Demographics
NPI:1811408081
Name:SMITH, TIFFANY DESIREE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DESIREE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5429 ESSEN LN APT 1
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3551
Mailing Address - Country:US
Mailing Address - Phone:318-564-9101
Mailing Address - Fax:
Practice Address - Street 1:9428 BROOKLINE AVE STE 2
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-1428
Practice Address - Country:US
Practice Address - Phone:225-372-2693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health