Provider Demographics
NPI:1275010795
Name:MORA, TIFFANY
Entity Type:Individual
Prefix:MISS
First Name:TIFFANY
Middle Name:
Last Name:MORA
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 1:2411 EMBLEM ST
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-9171
Mailing Address - Country:US
Mailing Address - Phone:775-335-6953
Mailing Address - Fax:
Practice Address - Street 1:140 CHISM ST APT 6
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-5549
Practice Address - Country:US
Practice Address - Phone:775-400-5518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0804914829106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV106S00000XMedicaid