Provider Demographics
NPI:1063969541
Name:EVANS, TIFFANY N
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:N
Last Name:EVANS
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 1:1026 GORDON DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-2212
Mailing Address - Country:US
Mailing Address - Phone:304-421-0854
Mailing Address - Fax:
Practice Address - Street 1:1026 GORDON DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-2212
Practice Address - Country:US
Practice Address - Phone:304-421-0854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-1798235Z00000X
WVP/SLP-0679235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist