Provider Demographics
NPI:1376232850
Name:THOMAS, TIFFANY CHEROND NICOLE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:CHEROND NICOLE
Last Name:THOMAS
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 1:22 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-1329
Mailing Address - Country:US
Mailing Address - Phone:209-640-2454
Mailing Address - Fax:
Practice Address - Street 1:430 N PILGRIM ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-4428
Practice Address - Country:US
Practice Address - Phone:209-466-0853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1202931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical