Provider Demographics
NPI:1285076257
Name:BRUNER, TIFFANY ROSHAWN
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ROSHAWN
Last Name:BRUNER
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 1:2520 N.W.39TH SUITE #100
Mailing Address - Street 2:
Mailing Address - City:OKC
Mailing Address - State:OK
Mailing Address - Zip Code:73112
Mailing Address - Country:US
Mailing Address - Phone:405-413-2077
Mailing Address - Fax:
Practice Address - Street 1:2520 NW 39TH EXPY STE 100
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3759
Practice Address - Country:US
Practice Address - Phone:405-413-2077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst