Provider Demographics
NPI:1770165375
Name:PHILLIPS, TIFFANY ANGEL (BCABA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANGEL
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5545 E STOP 11 RD APT C
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8616
Mailing Address - Country:US
Mailing Address - Phone:317-960-5437
Mailing Address - Fax:
Practice Address - Street 1:5545 E STOP 11 RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8616
Practice Address - Country:US
Practice Address - Phone:317-960-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0-21-12839103K00000X, 106E00000X
INRBT-18-61139106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician