Provider Demographics
NPI:1770721078
Name:DEHAVEN, TIFFANY MICHELLE (MED, PC)
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:MICHELLE
Last Name:DEHAVEN
Suffix:
Gender:F
Credentials:MED, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PEMBROKE CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-6404
Mailing Address - Country:US
Mailing Address - Phone:724-396-1510
Mailing Address - Fax:724-972-4627
Practice Address - Street 1:101 PEMBROKE CT
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-6404
Practice Address - Country:US
Practice Address - Phone:724-396-1510
Practice Address - Fax:724-972-4627
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-26
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0600049101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0378423Medicaid