Provider Demographics
NPI:1750673216
Name:BLACK, TIFFANY CLEVETTE
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:CLEVETTE
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3447 COBBLESTONE CT
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:OK
Mailing Address - Zip Code:73084-3258
Mailing Address - Country:US
Mailing Address - Phone:405-243-5514
Mailing Address - Fax:
Practice Address - Street 1:3447 COBBLESTONE CT
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:OK
Practice Address - Zip Code:73084-3258
Practice Address - Country:US
Practice Address - Phone:405-243-5514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation