Provider Demographics
NPI:1902338452
Name:MOORE, TIFFANY V (LIMHP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:V
Last Name:MOORE
Suffix:
Gender:F
Credentials:LIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 GOLD COAST RD
Mailing Address - Street 2:
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68046-4294
Mailing Address - Country:US
Mailing Address - Phone:402-215-4913
Mailing Address - Fax:531-200-9151
Practice Address - Street 1:11414 W CENTER RD STE 348
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-4420
Practice Address - Country:US
Practice Address - Phone:402-637-6778
Practice Address - Fax:531-200-9151
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2021-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1706101YM0800X
NE16871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026480123Medicaid
IA1902338452Medicaid