Provider Demographics
NPI:1700949633
Name:ANTON, TIFFANY (LMSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:ANTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1586
Mailing Address - Country:US
Mailing Address - Phone:734-788-8307
Mailing Address - Fax:
Practice Address - Street 1:120 W MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1586
Practice Address - Country:US
Practice Address - Phone:734-788-8307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010925551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH10024Medicaid
OH10034Medicaid