Provider Demographics
NPI:1992359046
Name:WILSON, TIFFANY ANDRAE
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:ANDRAE
Last Name:WILSON
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 1:5924 CLARENDON DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-5510
Mailing Address - Country:US
Mailing Address - Phone:779-207-6699
Mailing Address - Fax:
Practice Address - Street 1:145 S VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7226
Practice Address - Country:US
Practice Address - Phone:815-527-7300
Practice Address - Fax:815-356-6680
Is Sole Proprietor?:No
Enumeration Date:2019-07-27
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health