Basic Information
| Provider Information | |||||||||
| NPI: | 1356896153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGLISH | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LPCA, LCAS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 116 SEVEN MILE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287148509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286754116 | ||||||||
| FaxNumber: | 8286759312 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 SEVEN MILE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287148509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286754116 | ||||||||
| FaxNumber: | 8286759312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2016 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCAS-25080 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | A12426 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1356896153 | 05 | NC | MEDICAID |