Provider Demographics
NPI:1841762309
Name:LINDBECK, TIFFANY A
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:A
Last Name:LINDBECK
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 1:1615 SEMORAN NORTH CIR APT 103
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-1453
Mailing Address - Country:US
Mailing Address - Phone:407-745-8519
Mailing Address - Fax:
Practice Address - Street 1:12315 LAKE UNDERHILL RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4507
Practice Address - Country:US
Practice Address - Phone:321-972-4039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-21
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-50070106S00000X
FL106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024114600Medicaid