Provider Demographics
NPI:1275124968
Name:FONTAINE, TIFFANIE (LCSW-C)
Entity type:Individual
Prefix:
First Name:TIFFANIE
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:CONOWINGO
Mailing Address - State:MD
Mailing Address - Zip Code:21918-0099
Mailing Address - Country:US
Mailing Address - Phone:410-378-9696
Mailing Address - Fax:410-378-9922
Practice Address - Street 1:49 ROCK SPRINGS RD
Practice Address - Street 2:PO BOX 99
Practice Address - City:CONOWINGO
Practice Address - State:MD
Practice Address - Zip Code:21918
Practice Address - Country:US
Practice Address - Phone:410-378-9696
Practice Address - Fax:410-378-9922
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD229951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical