Provider Demographics
NPI:1821610213
Name:THOMPSON, TIFFANY LYNETTE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNETTE
Last Name:THOMPSON
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 1:4308 ANSAR LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-3128
Mailing Address - Country:US
Mailing Address - Phone:317-487-9874
Mailing Address - Fax:
Practice Address - Street 1:4308 ANSAR LN
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-3128
Practice Address - Country:US
Practice Address - Phone:317-487-9874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IN10135400101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA