Basic Information
| Provider Information | |||||||||
| NPI: | 1184802324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAVIS | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | N. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LGSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 FALLSWAY | ||||||||
| Address2: | RM # 2144 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212024800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108375533 | ||||||||
| FaxNumber: | 4108378020 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 FALLSWAY | ||||||||
| Address2: | RM # 2144 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212024800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108375533 | ||||||||
| FaxNumber: | 4108378020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2008 | ||||||||
| LastUpdateDate: | 01/21/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | G12347 | MD | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.