Provider Demographics
NPI:1114601903
Name:DEWITT, TIFFANY MICHELLE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MICHELLE
Last Name:DEWITT
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 1:719 SPENCER ST
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-3583
Mailing Address - Country:US
Mailing Address - Phone:574-721-9093
Mailing Address - Fax:
Practice Address - Street 1:719 SPENCER ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-3583
Practice Address - Country:US
Practice Address - Phone:574-721-9093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-23-255256106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician