Provider Demographics
NPI:1700619699
Name:CLARK, TIFFANY TENISE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:TENISE
Last Name:CLARK
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 1:401 E. 6TH ST
Mailing Address - Street 2:SUITE 219
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90014
Mailing Address - Country:US
Mailing Address - Phone:213-374-4055
Mailing Address - Fax:
Practice Address - Street 1:401 E. 6TH ST
Practice Address - Street 2:SUITE 219
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90014
Practice Address - Country:US
Practice Address - Phone:213-374-4055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health Worker