Provider Demographics
NPI:1629652664
Name:NICHOLS, TIFFANY RENAE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:RENAE
Last Name:NICHOLS
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 1:2782 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-1442
Mailing Address - Country:US
Mailing Address - Phone:440-328-9711
Mailing Address - Fax:
Practice Address - Street 1:13727 NOEL RD STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-1338
Practice Address - Country:US
Practice Address - Phone:972-851-1022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41704235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist