Provider Demographics
NPI:1891294096
Name:GARY, TIFFANY E
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:E
Last Name:GARY
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 1:193 TERRILL RD # 9
Mailing Address - Street 2:
Mailing Address - City:FANWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07023-1018
Mailing Address - Country:US
Mailing Address - Phone:973-380-9902
Mailing Address - Fax:
Practice Address - Street 1:193 TERRILL RD # 9
Practice Address - Street 2:
Practice Address - City:FANWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07023-1018
Practice Address - Country:US
Practice Address - Phone:973-380-9902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-03
Last Update Date:2018-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty