Provider Demographics
NPI:1740730134
Name:GRACIA, TIFFANEY
Entity type:Individual
Prefix:
First Name:TIFFANEY
Middle Name:
Last Name:GRACIA
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 1:4609 ANDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44055-3524
Mailing Address - Country:US
Mailing Address - Phone:440-714-1251
Mailing Address - Fax:
Practice Address - Street 1:22001 FAIRMONT
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118
Practice Address - Country:US
Practice Address - Phone:216-932-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1600934104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker