Provider Demographics
NPI:1003197781
Name:BERRY, TIFFANY JOANN
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:JOANN
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:HAWKINS-BERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:713 NW 138TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-1908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:713 NW 138TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-1908
Practice Address - Country:US
Practice Address - Phone:405-819-9599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKL082058339Medicaid