Provider Demographics
NPI:1740522598
Name:ELLISON, TIFFANY JILL
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:JILL
Last Name:ELLISON
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 1:4949 N HWY A1A APT 221
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34949-8243
Mailing Address - Country:US
Mailing Address - Phone:615-456-9739
Mailing Address - Fax:
Practice Address - Street 1:1986 31ST AVE
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6628
Practice Address - Country:US
Practice Address - Phone:772-581-2610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker