Provider Demographics
NPI:1508375148
Name:HERNDON, TIFFANY DAWN
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DAWN
Last Name:HERNDON
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 1:504 TEXAS ST
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-8807
Mailing Address - Country:US
Mailing Address - Phone:561-779-1908
Mailing Address - Fax:
Practice Address - Street 1:504 TEXAS ST
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-8807
Practice Address - Country:US
Practice Address - Phone:561-779-1908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-27
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75431101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty