Provider Demographics
NPI:1083202436
Name:O'CONNOR, TIFFANY K (LAC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:K
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 E DEL RIO DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-3918
Mailing Address - Country:US
Mailing Address - Phone:480-544-1036
Mailing Address - Fax:
Practice Address - Street 1:3303 E BASELINE RD STE 109
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2739
Practice Address - Country:US
Practice Address - Phone:480-900-8765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-12798101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health