Provider Demographics
NPI:1811597883
Name:STEWART, TIFFANY MARIE (BEHAVIOR TECHNICIAN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:STEWART
Suffix:
Gender:F
Credentials:BEHAVIOR TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 CEDAR HILL STREET SUITE 200
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752
Mailing Address - Country:US
Mailing Address - Phone:702-518-1446
Mailing Address - Fax:
Practice Address - Street 1:255 CEDAR HILL STREET SUITE 200
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752
Practice Address - Country:US
Practice Address - Phone:702-518-1446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO041751307Medicaid