Provider Demographics
NPI:1376154203
Name:SHORT, TIFFANY ANN (BCBA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:SHORT
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 OTTEN LN
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-3091
Mailing Address - Country:US
Mailing Address - Phone:618-528-0273
Mailing Address - Fax:
Practice Address - Street 1:1955 STATE ROUTE 146 E
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-3501
Practice Address - Country:US
Practice Address - Phone:618-833-4774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL12043627103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst