Provider Demographics
NPI:1336756618
Name:BASKETT, TIFFANY DELORES (LCAS-A)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DELORES
Last Name:BASKETT
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5171 GLENWOOD AVE STE 211
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3266
Mailing Address - Country:US
Mailing Address - Phone:919-783-8898
Mailing Address - Fax:
Practice Address - Street 1:6026 SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-3899
Practice Address - Country:US
Practice Address - Phone:919-658-8710
Practice Address - Fax:919-477-1848
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 172V00000X
NCLCAS-27501101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No172V00000XOther Service ProvidersCommunity Health Worker