Provider Demographics
NPI:1790067213
Name:ONTIVEROS, TIFFANY A (MS)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:A
Last Name:ONTIVEROS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S MARTIN LUTHER KING BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4309
Mailing Address - Country:US
Mailing Address - Phone:702-486-5004
Mailing Address - Fax:
Practice Address - Street 1:121 S MARTIN LUTHER KING BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4309
Practice Address - Country:US
Practice Address - Phone:702-486-5004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-10
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health