Provider Demographics
NPI:1982138970
Name:GLENN, TIFFANY STAR (LMT)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:STAR
Last Name:GLENN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2999 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-1428
Mailing Address - Country:US
Mailing Address - Phone:937-888-0657
Mailing Address - Fax:
Practice Address - Street 1:2999 E HIGH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-1428
Practice Address - Country:US
Practice Address - Phone:937-888-0657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.023091405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional