Provider Demographics
NPI:1770995086
Name:WHITE, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WHITE
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 1:1025 DOVE RUN RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-3588
Mailing Address - Country:US
Mailing Address - Phone:859-269-6465
Mailing Address - Fax:
Practice Address - Street 1:1025 DOVE RUN RD
Practice Address - Street 2:SUITE 304
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-3588
Practice Address - Country:US
Practice Address - Phone:859-269-6465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0996103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist