Provider Demographics
NPI:1477275477
Name:FAGAN, TIFFANY ROCHELLE (RBT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ROCHELLE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3183
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95344-1183
Mailing Address - Country:US
Mailing Address - Phone:209-535-0950
Mailing Address - Fax:
Practice Address - Street 1:2504 3RD AVE
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-3010
Practice Address - Country:US
Practice Address - Phone:209-720-9380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA700251106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA700251OtherRBT