Provider Demographics
NPI:1295431484
Name:MICEK, TIFFANY (LCSW)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MICEK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-2059
Mailing Address - Country:US
Mailing Address - Phone:847-773-7474
Mailing Address - Fax:
Practice Address - Street 1:1860 W WINCHESTER RD STE 205
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5317
Practice Address - Country:US
Practice Address - Phone:224-424-4102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150106104104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker