Provider Demographics
NPI:1033637699
Name:MOORE, TIFFANIE (NCSP, BCBA)
Entity Type:Individual
Prefix:
First Name:TIFFANIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:NCSP, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 LIBERTY LN
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-9432
Mailing Address - Country:US
Mailing Address - Phone:405-548-1029
Mailing Address - Fax:817-549-3172
Practice Address - Street 1:600 LIBERTY LN
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034
Practice Address - Country:US
Practice Address - Phone:405-548-1029
Practice Address - Fax:817-549-3172
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11416638103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst