Provider Demographics
NPI:1720408750
Name:MATLOCK, TIFFANY (PLMHP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8506 N 83RD AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68122-4013
Mailing Address - Country:US
Mailing Address - Phone:402-213-4603
Mailing Address - Fax:
Practice Address - Street 1:8506 N 83RD AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68122-4013
Practice Address - Country:US
Practice Address - Phone:402-213-4603
Practice Address - Fax:402-572-1616
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9833101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health