Provider Demographics
NPI:1376923110
Name:CHAN, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:CHAN
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 1:1479 SHIRLEY DR
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-2628
Mailing Address - Country:US
Mailing Address - Phone:707-980-1004
Mailing Address - Fax:
Practice Address - Street 1:1421 BRODERICK ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3304
Practice Address - Country:US
Practice Address - Phone:415-292-1760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-07
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health