Provider Demographics
NPI:1700472024
Name:YOUNG, TIFFANY NICHOLE
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:NICHOLE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:TIFFANY
Other - Middle Name:NICHOLE
Other - Last Name:WINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16251 AMBIA CIR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8437
Mailing Address - Country:US
Mailing Address - Phone:317-727-1876
Mailing Address - Fax:
Practice Address - Street 1:6330 E 75TH ST STE 206
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2700
Practice Address - Country:US
Practice Address - Phone:317-284-1166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty