Provider Demographics
NPI:1578059259
Name:DAVID, TIFFANY LACY (BCBA, LBA)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:LACY
Last Name:DAVID
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:LACY
Other - Last Name:OWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:226 W PRIEN LAKE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8781
Mailing Address - Country:US
Mailing Address - Phone:337-240-2779
Mailing Address - Fax:
Practice Address - Street 1:226 W PRIEN LAKE RD STE 3
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8781
Practice Address - Country:US
Practice Address - Phone:337-240-2779
Practice Address - Fax:337-882-2111
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-588103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1-18-30334OtherCLASS TULSA, LLC