Provider Demographics
NPI:1679390579
Name:KORNMANN, TIFFANY CASON (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:CASON
Last Name:KORNMANN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2506
Mailing Address - Country:US
Mailing Address - Phone:314-471-1402
Mailing Address - Fax:
Practice Address - Street 1:1604 EASTPORT PLAZA DR STE 102
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-6133
Practice Address - Country:US
Practice Address - Phone:618-346-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20100395101041C0700X
IL1490274351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical