Provider Demographics
NPI:1821545922
Name:WILCKEN, TIFFANY (MAS LAMFT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WILCKEN
Suffix:
Gender:F
Credentials:MAS LAMFT
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:WILCKEN
Other - Last Name:MOSER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MAS LAMFT
Mailing Address - Street 1:19242 S 199TH PL
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-9395
Mailing Address - Country:US
Mailing Address - Phone:480-329-5781
Mailing Address - Fax:
Practice Address - Street 1:19242 S 199TH PL
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-9395
Practice Address - Country:US
Practice Address - Phone:480-329-5781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAMFT-10511106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist