Provider Demographics
NPI:1205587292
Name:MACK, TIFFANY DANIELLE (LSW)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DANIELLE
Last Name:MACK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 AVALON WAY APT 7436
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-7026
Mailing Address - Country:US
Mailing Address - Phone:908-295-9888
Mailing Address - Fax:
Practice Address - Street 1:151 KNOLLCROFT RD BLDG 53
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NJ
Practice Address - Zip Code:07939-5001
Practice Address - Country:US
Practice Address - Phone:908-647-0180
Practice Address - Fax:908-604-5836
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC062323001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical