Provider Demographics
NPI:1861089948
Name:LEAL, TIFFANY ALEXIS
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ALEXIS
Last Name:LEAL
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 1:3901 S FIFE ST STE 301
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7309
Mailing Address - Country:US
Mailing Address - Phone:253-589-5334
Mailing Address - Fax:
Practice Address - Street 1:3901 S FIFE ST STE 301
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7309
Practice Address - Country:US
Practice Address - Phone:253-589-5334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WAMG61473165106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA27-0342521Medicaid