Provider Demographics
NPI:1285953604
Name:MCLALLEN, TIFFANY SHAWN
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:SHAWN
Last Name:MCLALLEN
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 1:218 STONE ST
Mailing Address - Street 2:2 FLOOR
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3211
Mailing Address - Country:US
Mailing Address - Phone:315-782-7445
Mailing Address - Fax:315-779-1184
Practice Address - Street 1:218 STONE ST
Practice Address - Street 2:2 FLOOR
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3211
Practice Address - Country:US
Practice Address - Phone:315-782-7445
Practice Address - Fax:315-779-1184
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP75075101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health