Provider Demographics
NPI:1174863484
Name:MOORE, TIFFANY MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:MICHELLE
Last Name:MOORE
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 1:1621 1/2 N MARTEL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-3508
Mailing Address - Country:US
Mailing Address - Phone:509-539-6966
Mailing Address - Fax:
Practice Address - Street 1:525 N GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1202
Practice Address - Country:US
Practice Address - Phone:509-539-6966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18989235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist