Provider Demographics
NPI:1730431115
Name:ALSTON, TIFFANY T (TIFFANY)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:T
Last Name:ALSTON
Suffix:
Gender:F
Credentials:TIFFANY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 PACIFIC TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0503
Mailing Address - Country:US
Mailing Address - Phone:702-372-4624
Mailing Address - Fax:
Practice Address - Street 1:1313 PACIFIC TERRACE DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0503
Practice Address - Country:US
Practice Address - Phone:702-372-4624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225400000X103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation