Provider Demographics
NPI:1477057867
Name:KING, TIFFANY NICOLA
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLA
Last Name:KING
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 1:19504 CRYSTAL ROCK DR APT 22
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-4908
Mailing Address - Country:US
Mailing Address - Phone:256-503-4340
Mailing Address - Fax:
Practice Address - Street 1:19504 CRYSTAL ROCK DR APT 22
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-4908
Practice Address - Country:US
Practice Address - Phone:256-503-4340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician