Provider Demographics
NPI:1790408870
Name:PARK, TIFFANY DEBORAH (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DEBORAH
Last Name:PARK
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 1:2700 UNIVERSITY AVE W APT 145
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1752
Mailing Address - Country:US
Mailing Address - Phone:714-313-7863
Mailing Address - Fax:
Practice Address - Street 1:2700 UNIVERSITY AVE W APT 145
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1752
Practice Address - Country:US
Practice Address - Phone:714-313-7863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32937235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist