Provider Demographics
NPI:1952110983
Name:WILSON, TIFFANY (MFT, LCDC, LSOTP)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MFT, LCDC, LSOTP
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:ROSCHYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 POSTMASTER DR UNIT 876
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-2808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4220 CARTWRIGHT RD STE 401
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-5310
Practice Address - Country:US
Practice Address - Phone:346-440-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-03
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA203929106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist