Provider Demographics
NPI:1235680232
Name:WYMORE, TIFFANY NICOLE (MA,PLPC)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:NICOLE
Last Name:WYMORE
Suffix:
Gender:F
Credentials:MA,PLPC
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:NICOLE
Other - Last Name:PELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:227 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028
Mailing Address - Country:US
Mailing Address - Phone:636-931-2700
Mailing Address - Fax:636-931-5304
Practice Address - Street 1:227 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028
Practice Address - Country:US
Practice Address - Phone:636-931-2700
Practice Address - Fax:636-931-5304
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016034260101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health