Provider Demographics
NPI:1831949833
Name:MADSON, TIFFANY LYNN (LPCC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNN
Last Name:MADSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19280 GRAVE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-4735
Mailing Address - Country:US
Mailing Address - Phone:612-750-0291
Mailing Address - Fax:
Practice Address - Street 1:13045 FALCON DR STE 100
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-4201
Practice Address - Country:US
Practice Address - Phone:218-829-9307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC04185101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health