Provider Demographics
NPI:1104453836
Name:FLIPPEN, TIFFANY SHELL (LSAA)
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:SHELL
Last Name:FLIPPEN
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:SHELL
Other - Last Name:SALAMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1120 INWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020
Mailing Address - Country:US
Mailing Address - Phone:505-409-3945
Mailing Address - Fax:
Practice Address - Street 1:1016 E. ROOSEVELT AVE.
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020
Practice Address - Country:US
Practice Address - Phone:505-287-5211
Practice Address - Fax:505-287-6737
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00729Medicaid