Provider Demographics
NPI:1104545151
Name:ALLEN, TIFFANY ROSE (MA,LAMFT)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ROSE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MA,LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6375 W 143RD ST
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2888
Mailing Address - Country:US
Mailing Address - Phone:612-965-2545
Mailing Address - Fax:
Practice Address - Street 1:1303 S FRONTAGE RD STE 271
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-2691
Practice Address - Country:US
Practice Address - Phone:612-965-2545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN101YM0800XMedicaid