Provider Demographics
NPI:1316450919
Name:WICKS, TIFFANY (LPC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WICKS
Suffix:
Gender:
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1934 OLD GALLOWS RD
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-4042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1934 OLD GALLOWS RD
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-4042
Practice Address - Country:US
Practice Address - Phone:571-622-3984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2025-03-21
Deactivation Date:2024-12-16
Deactivation Code:
Reactivation Date:2025-03-21
Provider Licenses
StateLicense IDTaxonomies
TX71311101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional