1548419377 NPI number — TIFFANY E BLACK LPC

Table of content: TIFFANY E BLACK LPC (NPI 1548419377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548419377 NPI number — TIFFANY E BLACK LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
TIFFANY
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548419377
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 S 48TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGDALE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72762-6683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-750-2020
Provider Business Mailing Address Fax Number:
479-750-4843

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 W SUNBRIDGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72703-1822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-695-1240
Provider Business Practice Location Address Fax Number:
479-750-4843
Provider Enumeration Date:
09/17/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  P1308084 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)