Provider Demographics
NPI:1457052771
Name:FOJTASEK, TIFFANY BRADFORD (MA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:BRADFORD
Last Name:FOJTASEK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 163781
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-3781
Mailing Address - Country:US
Mailing Address - Phone:682-651-7621
Mailing Address - Fax:817-887-3409
Practice Address - Street 1:1285 N MAIN ST STE 101-5
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-1511
Practice Address - Country:US
Practice Address - Phone:682-651-7621
Practice Address - Fax:817-887-3409
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX90162101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional