Provider Demographics
NPI:1144861808
Name:MARTIN, TIFFANY MONIQUE
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:MONIQUE
Last Name:MARTIN
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 1:127 MUIR WOODS RD
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-5573
Mailing Address - Country:US
Mailing Address - Phone:951-394-3736
Mailing Address - Fax:
Practice Address - Street 1:41715 ENTERPRISE CIR N STE 102
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5661
Practice Address - Country:US
Practice Address - Phone:951-290-2997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist