Provider Demographics
NPI:1740514272
Name:KALLHOVD, TIFFANY DERBY (LMSW, CASAC)
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:DERBY
Last Name:KALLHOVD
Suffix:
Gender:F
Credentials:LMSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4519 42ND ST
Mailing Address - Street 2:APT 4A
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-2974
Mailing Address - Country:US
Mailing Address - Phone:631-445-8875
Mailing Address - Fax:
Practice Address - Street 1:4519 42ND ST
Practice Address - Street 2:APT 4A
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-2974
Practice Address - Country:US
Practice Address - Phone:631-445-8875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0756431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical