Provider Demographics
NPI:1346575388
Name:SYBESMA, TIFFANY LYNAE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNAE
Last Name:SYBESMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:LYNAE
Other - Last Name:BYLSMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1800 TULLY RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-2946
Mailing Address - Country:US
Mailing Address - Phone:209-576-1750
Mailing Address - Fax:
Practice Address - Street 1:1800 TULLY RD
Practice Address - Street 2:SUITE F
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-2946
Practice Address - Country:US
Practice Address - Phone:209-576-1750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-08
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
CA326101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program