Provider Demographics
NPI:1801973375
Name:BOSTER-POOR, TIFFANY ANN (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:BOSTER-POOR
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12108 LIBERTY HILL RD
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:OK
Mailing Address - Zip Code:74932-2152
Mailing Address - Country:US
Mailing Address - Phone:479-652-0302
Mailing Address - Fax:
Practice Address - Street 1:12108 LIBERTY HILL RD
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:OK
Practice Address - Zip Code:74932-2152
Practice Address - Country:US
Practice Address - Phone:479-652-0302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1971235Z00000X
OK6097235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149608721Medicaid