Provider Demographics
NPI:1215685615
Name:GLASS, TIFFANY COLLEEN
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:COLLEEN
Last Name:GLASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 JEFFERSON ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504-1724
Mailing Address - Country:US
Mailing Address - Phone:855-284-7483
Mailing Address - Fax:617-807-0958
Practice Address - Street 1:102 COUNTRY CLUB PKWY STE A
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-7048
Practice Address - Country:US
Practice Address - Phone:855-284-7483
Practice Address - Fax:617-807-0958
Is Sole Proprietor?:No
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR202198103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical