Provider Demographics
NPI:1831654961
Name:GIFFORD, JOHN TYLER (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TYLER
Last Name:GIFFORD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 HAY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5312
Mailing Address - Country:US
Mailing Address - Phone:910-860-7008
Mailing Address - Fax:910-221-9006
Practice Address - Street 1:806 HAY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5312
Practice Address - Country:US
Practice Address - Phone:910-860-7008
Practice Address - Fax:910-221-9006
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-03
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0123651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical