Provider Demographics
NPI:1770218919
Name:SEGOVIA, TIFFANY M
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:M
Last Name:SEGOVIA
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 1:21 HAGERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2108
Mailing Address - Country:US
Mailing Address - Phone:934-222-4222
Mailing Address - Fax:
Practice Address - Street 1:21 HAGERMAN AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2108
Practice Address - Country:US
Practice Address - Phone:934-222-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst