Provider Demographics
NPI:1619754942
Name:LONG, TIFFANY LYNN
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNN
Last Name:LONG
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 1:180 DON CIR
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36360-1311
Mailing Address - Country:US
Mailing Address - Phone:205-337-3973
Mailing Address - Fax:
Practice Address - Street 1:807 DONNELL BLVD STE Q
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36322-2111
Practice Address - Country:US
Practice Address - Phone:334-709-4024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-23-288317106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician