Provider Demographics
NPI:1225374937
Name:TEAGARDEN-BROWN, TIFFANYE
Entity Type:Individual
Prefix:
First Name:TIFFANYE
Middle Name:
Last Name:TEAGARDEN-BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIFFANYE
Other - Middle Name:
Other - Last Name:TEAGARDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-0663
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2242 S TELEGRAPH RD STE 209
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0218
Practice Address - Country:US
Practice Address - Phone:248-797-1188
Practice Address - Fax:248-847-1346
Is Sole Proprietor?:No
Enumeration Date:2012-12-27
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013040101Y00000X, 101YP2500X
MI4101006543106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI13645747OtherCAQH