Provider Demographics
NPI:1275168221
Name:ROE, TIFFANY NICOLE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:ROE
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 1:3637 ROLLING LANE CIR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-1219
Mailing Address - Country:US
Mailing Address - Phone:928-846-1833
Mailing Address - Fax:
Practice Address - Street 1:3637 ROLLING LANE CIR
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-1219
Practice Address - Country:US
Practice Address - Phone:928-846-1833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst