Provider Demographics
NPI:1053976118
Name:CLARKE, TIFFANY SHANAE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:SHANAE
Last Name:CLARKE
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 1:104 BALA AVE
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-3038
Mailing Address - Country:US
Mailing Address - Phone:484-734-0427
Mailing Address - Fax:
Practice Address - Street 1:104 BALA AVE
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-3038
Practice Address - Country:US
Practice Address - Phone:484-734-0427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-04
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical