Provider Demographics
NPI:1376127126
Name:TIFFANY M. BOARDS
Entity type:Organization
Organization Name:TIFFANY M. BOARDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BOARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:734-561-4102
Mailing Address - Street 1:1120 CHICAGO BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-1419
Mailing Address - Country:US
Mailing Address - Phone:734-561-4102
Mailing Address - Fax:
Practice Address - Street 1:20411 W 12 MILE RD STE 208
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-6405
Practice Address - Country:US
Practice Address - Phone:734-561-4102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. TIFFANY BOARDS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-07
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty