Provider Demographics
NPI:1780228569
Name:BAXTER, TIFFANY JEAN
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:JEAN
Last Name:BAXTER
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 1:213 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2926
Mailing Address - Country:US
Mailing Address - Phone:619-552-1446
Mailing Address - Fax:
Practice Address - Street 1:213 2ND AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2926
Practice Address - Country:US
Practice Address - Phone:619-552-1446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician