Provider Demographics
NPI:1447621602
Name:SMALLS-WILSON, TIFFANY (LMFT)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:SMALLS-WILSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 TILDEN ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-6013
Mailing Address - Country:US
Mailing Address - Phone:718-231-3400
Mailing Address - Fax:718-655-3503
Practice Address - Street 1:750 TILDEN ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-6013
Practice Address - Country:US
Practice Address - Phone:718-231-3400
Practice Address - Fax:718-655-3503
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001167106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist