Provider Demographics
NPI:1770334831
Name:CLOUSE, TIFFANY MARIE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:CLOUSE
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:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:ND
Mailing Address - Zip Code:58367-0303
Mailing Address - Country:US
Mailing Address - Phone:701-370-2208
Mailing Address - Fax:
Practice Address - Street 1:603 5TH ST NE
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:ND
Practice Address - Zip Code:58367-7329
Practice Address - Country:US
Practice Address - Phone:701-370-2208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND39431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty