Provider Demographics
NPI:1629787858
Name:ANDERSON, TIFFANY (M ED, BCABA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:M ED, BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:373 S WILLOW ST STE 266
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-5751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:336 HALLS HILL RD
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-1452
Practice Address - Country:US
Practice Address - Phone:860-603-2243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-16
Last Update Date:2024-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1840106E00000X
CTRBT-22-243226106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician