Provider Demographics
NPI:1356728224
Name:WILSON, TIFFANIE M (LPC, LCDC)
Entity type:Individual
Prefix:MS
First Name:TIFFANIE
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10333 RESEARCH FOREST DR
Mailing Address - Street 2:#737
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-6162
Mailing Address - Country:US
Mailing Address - Phone:281-210-4794
Mailing Address - Fax:
Practice Address - Street 1:10333 RESEARCH FOREST DR
Practice Address - Street 2:#737
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-6162
Practice Address - Country:US
Practice Address - Phone:832-510-0432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12552101YA0400X
TX72327101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)