Provider Demographics
NPI:1588445795
Name:GREENWALD, TIFFANY ANN (CMA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:GREENWALD
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-1434
Mailing Address - Country:US
Mailing Address - Phone:989-356-2161
Mailing Address - Fax:989-354-5898
Practice Address - Street 1:400 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1434
Practice Address - Country:US
Practice Address - Phone:989-356-2161
Practice Address - Fax:989-354-5898
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1881860658103T00000X
MI1295264034103T00000X
MI1003122169363AM0700X
MI1457081036363LP0808X
MI1043404924103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health