Provider Demographics
NPI:1295158061
Name:LONGJOHN, TIFFANY NICOLE (MS, NCC, LPCA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:LONGJOHN
Suffix:
Gender:F
Credentials:MS, NCC, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4906
Mailing Address - Country:US
Mailing Address - Phone:336-760-1330
Mailing Address - Fax:336-760-1341
Practice Address - Street 1:1510 MARTIN ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4906
Practice Address - Country:US
Practice Address - Phone:336-760-1330
Practice Address - Fax:336-760-1341
Is Sole Proprietor?:No
Enumeration Date:2014-01-29
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA10578101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health