Provider Demographics
NPI:1336801281
Name:GREEN, TIFFANY (MED, NCC, LPC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MED, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27280
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-8280
Mailing Address - Country:US
Mailing Address - Phone:203-912-0254
Mailing Address - Fax:
Practice Address - Street 1:1408 MARK CT
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76108-3568
Practice Address - Country:US
Practice Address - Phone:203-912-0254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5194101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional