Provider Demographics
NPI:1083014302
Name:SHADER, TIFFANY MARIE (PHD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:SHADER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 HORIZONS DR.
Mailing Address - Street 2:STE 202, OFFICE 203
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-5280
Mailing Address - Country:US
Mailing Address - Phone:714-357-7810
Mailing Address - Fax:
Practice Address - Street 1:4100 HORIZONS DR.
Practice Address - Street 2:STE 202, OFFICE 203
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220
Practice Address - Country:US
Practice Address - Phone:614-355-8160
Practice Address - Fax:614-355-8180
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32997103T00000X
OHP.08452103T00000X
MO2021001238103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid