Provider Demographics
NPI:1659800522
Name:ANDERSON, TIFFANY (PHD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3671 BUSINESS DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-2233
Mailing Address - Country:US
Mailing Address - Phone:916-732-8966
Mailing Address - Fax:
Practice Address - Street 1:3671 BUSINESS DR STE 110
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-2233
Practice Address - Country:US
Practice Address - Phone:916-732-8966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 390200000X
CA34394103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program