Provider Demographics
NPI:1801598586
Name:COULTER, TIFFANY KETRON (LCSW)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:KETRON
Last Name:COULTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:KETRON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 902
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-0902
Mailing Address - Country:US
Mailing Address - Phone:804-837-5945
Mailing Address - Fax:
Practice Address - Street 1:10128 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3300
Practice Address - Country:US
Practice Address - Phone:804-837-5945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040147441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical