Provider Demographics
NPI:1497102933
Name:MARTIN, TIFFANI (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANI
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 W SOUTH 1ST ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534-9086
Mailing Address - Country:US
Mailing Address - Phone:970-231-2681
Mailing Address - Fax:
Practice Address - Street 1:305 W SOUTH 1ST ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534-9086
Practice Address - Country:US
Practice Address - Phone:970-231-2681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13664103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist