Provider Demographics
NPI:1134582471
Name:TODD, TIFFANY (LCSW)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:TODD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:MCQUEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 CALIFORNIA STREET
Mailing Address - Street 2:PO BOX 577
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:618-985-4635
Practice Address - Street 1:3111 WILLIAMSON COUNTY PKWY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5235
Practice Address - Country:US
Practice Address - Phone:618-519-9200
Practice Address - Fax:618-985-9155
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0175091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN370966854006Medicaid
IN370966854006Medicaid