Provider Demographics
NPI:1871760082
Name:STURDIVANT, TIFFANY R (MSW,LCSW)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:R
Last Name:STURDIVANT
Suffix:
Gender:F
Credentials:MSW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64127-2544
Mailing Address - Country:US
Mailing Address - Phone:816-404-5752
Mailing Address - Fax:
Practice Address - Street 1:300 W 19TH TER
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2026
Practice Address - Country:US
Practice Address - Phone:816-404-5755
Practice Address - Fax:816-404-5751
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MO20080265441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494074602Medicaid