Provider Demographics
NPI:1639476211
Name:MOORE, TIFFINY JEAN (LCMHC)
Entity Type:Individual
Prefix:
First Name:TIFFINY
Middle Name:JEAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:TIFFINY
Other - Middle Name:JEAN
Other - Last Name:HUBBARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCMHC
Mailing Address - Street 1:PO BOX 853
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0853
Mailing Address - Country:US
Mailing Address - Phone:802-793-9144
Mailing Address - Fax:
Practice Address - Street 1:297 N MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-4503
Practice Address - Country:US
Practice Address - Phone:802-793-9144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-17
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0057639101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1018762Medicaid