Provider Demographics
NPI:1902294861
Name:GHOLSON, TIFFANY CHERYL (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:CHERYL
Last Name:GHOLSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 N JEFFERSON ST
Mailing Address - Street 2:SUITE 2207
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-1226
Mailing Address - Country:US
Mailing Address - Phone:217-202-8433
Mailing Address - Fax:
Practice Address - Street 1:365 N JEFFERSON ST
Practice Address - Street 2:SUITE 2207
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-1226
Practice Address - Country:US
Practice Address - Phone:217-202-8433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0144401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical