Provider Demographics
NPI:1407611486
Name:HOLDERMAN, TIFFANY MARIE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:HOLDERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:MARIE
Other - Last Name:BARTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11174 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48353-2702
Mailing Address - Country:US
Mailing Address - Phone:810-991-1114
Mailing Address - Fax:
Practice Address - Street 1:11174 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:MI
Practice Address - Zip Code:48353-2702
Practice Address - Country:US
Practice Address - Phone:810-991-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIH436793585345106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician