Provider Demographics
NPI:1710178298
Name:SURMAN, TIFFANY JENEEN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:JENEEN
Last Name:SURMAN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:J
Other - Last Name:BLIESNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:2324 W STEED RDG
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-0700
Mailing Address - Country:US
Mailing Address - Phone:785-375-5143
Mailing Address - Fax:
Practice Address - Street 1:3141 N 3RD AVE STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4351
Practice Address - Country:US
Practice Address - Phone:785-375-5143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP5590235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ569676Medicaid