Provider Demographics
NPI:1518216100
Name:PIETERS, TYFFANI R (CCC-SLP)
Entity type:Individual
Prefix:
First Name:TYFFANI
Middle Name:R
Last Name:PIETERS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S HIGHWAY 27 STE B201
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6816
Mailing Address - Country:US
Mailing Address - Phone:352-394-0212
Mailing Address - Fax:352-241-6361
Practice Address - Street 1:2400 S HIGHWAY 27 STE B201
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711
Practice Address - Country:US
Practice Address - Phone:352-394-0212
Practice Address - Fax:352-241-6361
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11424235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006533200Medicaid