Provider Demographics
NPI:1568990927
Name:CONNER, TIFFANY MARIE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:CONNER
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 1:13045 FALCON DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-4201
Mailing Address - Country:US
Mailing Address - Phone:218-829-9307
Mailing Address - Fax:
Practice Address - Street 1:13045 FALCON DR STE 100
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-4201
Practice Address - Country:US
Practice Address - Phone:218-829-9307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2017-039-A106H00000X
MN3703106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist