Provider Demographics
NPI:1457833261
Name:TIFFANY ANN AVON PSY D PC
Entity Type:Organization
Organization Name:TIFFANY ANN AVON PSY D PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:AVON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:917-887-2783
Mailing Address - Street 1:20 CANTERBURY LN
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-1102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:585 PLANDOME RD STE 105
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-1971
Practice Address - Country:US
Practice Address - Phone:917-887-2783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-29
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020146103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY020146OtherLICENSE