Provider Demographics
NPI:1548926124
Name:LARUSSO, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:LARUSSO
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 1:7 REGENT ST STE 708
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-1628
Mailing Address - Country:US
Mailing Address - Phone:551-237-4646
Mailing Address - Fax:
Practice Address - Street 1:7 REGENT ST STE 708
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-1628
Practice Address - Country:US
Practice Address - Phone:551-237-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-23-66313103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-21-158668OtherRBT CERT