Provider Demographics
NPI:1417688623
Name:LEARY, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:LEARY
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 1:704 W SUL ROSS AVE
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:TX
Mailing Address - Zip Code:79830-4428
Mailing Address - Country:US
Mailing Address - Phone:432-837-3315
Mailing Address - Fax:
Practice Address - Street 1:1905 W MOSLEY LOOP
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:TX
Practice Address - Zip Code:79830-5303
Practice Address - Country:US
Practice Address - Phone:806-773-1123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-19
Last Update Date:2022-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist