Provider Demographics
NPI:1134295306
Name:HUIZENGA, TIFFANY MARIE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:MARIE
Last Name:HUIZENGA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S ABILENE
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130
Mailing Address - Country:US
Mailing Address - Phone:505-359-3707
Mailing Address - Fax:505-356-6682
Practice Address - Street 1:501 S ABILENE
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130
Practice Address - Country:US
Practice Address - Phone:505-359-3707
Practice Address - Fax:505-356-6682
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC3990235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39008371Medicaid