Provider Demographics
NPI:1760611784
Name:WALLACE, TIFFANI LYN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:TIFFANI
Middle Name:LYN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1642 WARHAWK RD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-8737
Mailing Address - Country:US
Mailing Address - Phone:765-689-9363
Mailing Address - Fax:
Practice Address - Street 1:1642 WARHAWK RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-8737
Practice Address - Country:US
Practice Address - Phone:765-689-9363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-12
Last Update Date:2009-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003751A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist