Provider Demographics
NPI:1245842046
Name:JOHNSON, TIFFANY (C-SAC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:C-SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-3709
Mailing Address - Country:US
Mailing Address - Phone:715-392-1955
Mailing Address - Fax:715-392-1935
Practice Address - Street 1:2222 E 5TH ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-3709
Practice Address - Country:US
Practice Address - Phone:715-392-1955
Practice Address - Fax:715-392-1935
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17142-32101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)