Provider Demographics
NPI:1801449996
Name:GREEN, TIFFANI
Entity type:Individual
Prefix:
First Name:TIFFANI
Middle Name:
Last Name:GREEN
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 1:301 S TUBB ST STE A1
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34760-8859
Mailing Address - Country:US
Mailing Address - Phone:407-395-9976
Mailing Address - Fax:
Practice Address - Street 1:678 W BAY ST APT 52
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787
Practice Address - Country:US
Practice Address - Phone:516-425-4905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician