Provider Demographics
NPI:1275763997
Name:PETERS, TIFFNEY (MSW, PHD)
Entity Type:Individual
Prefix:
First Name:TIFFNEY
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:MSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 PIKE RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-3119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:WILFORD HALL AMBULATORY SURGICAL CENTER
Practice Address - Street 2:1100 WILFORD HALL LOOP, BLDG 4554
Practice Address - City:JBSA-LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:210-292-6016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
KY36571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid