Provider Demographics
NPI:1952932014
Name:GOODELL, TIFFANY (LMHC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:GOODELL
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-4229
Mailing Address - Country:US
Mailing Address - Phone:973-979-9882
Mailing Address - Fax:
Practice Address - Street 1:177 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-4229
Practice Address - Country:US
Practice Address - Phone:973-979-9882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007955101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty