Provider Demographics
NPI:1104477652
Name:DERKSEN, TIFFANY (TLLP)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:DERKSEN
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7305 GRAND RIVER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7378
Mailing Address - Country:US
Mailing Address - Phone:734-961-7196
Mailing Address - Fax:734-961-7187
Practice Address - Street 1:7305 GRAND RIVER RD STE 300
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7378
Practice Address - Country:US
Practice Address - Phone:734-961-7196
Practice Address - Fax:734-961-7187
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018112103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty