Provider Demographics
NPI:1851910459
Name:BURROUGHS, TIANNA RENE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TIANNA
Middle Name:RENE
Last Name:BURROUGHS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S WALNUT ST STE 11
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-6118
Mailing Address - Country:US
Mailing Address - Phone:812-287-8630
Mailing Address - Fax:
Practice Address - Street 1:205 S WALNUT ST STE 11
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-6118
Practice Address - Country:US
Practice Address - Phone:812-287-8630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN72461041C0700X
IN34006307A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical