Provider Demographics
NPI:1255039194
Name:LONG, TIFFANY D
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:D
Last Name:LONG
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 1:14502 GREENVIEW DR STE 202
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-3287
Mailing Address - Country:US
Mailing Address - Phone:240-581-1500
Mailing Address - Fax:240-513-4122
Practice Address - Street 1:14502 GREENVIEW DR STE 202
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-3287
Practice Address - Country:US
Practice Address - Phone:240-581-1500
Practice Address - Fax:240-513-4122
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP13111101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional