Provider Demographics
NPI:1104131804
Name:GENTILE, TIFFANY JANE (MS LMHC CEDS NCC CAS)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:JANE
Last Name:GENTILE
Suffix:
Gender:F
Credentials:MS LMHC CEDS NCC CAS
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:JANE
Other - Last Name:BURDICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:188 SOUTH 3RD STREET
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069
Mailing Address - Country:US
Mailing Address - Phone:315-207-5435
Mailing Address - Fax:315-410-5544
Practice Address - Street 1:188 S 3RD ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1801
Practice Address - Country:US
Practice Address - Phone:315-591-7007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005109-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health