Provider Demographics
NPI:1104632207
Name:PAGE, TIFFANY M (ACMHC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:M
Last Name:PAGE
Suffix:
Gender:F
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1152 W 2450 N
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-9194
Mailing Address - Country:US
Mailing Address - Phone:801-644-3778
Mailing Address - Fax:
Practice Address - Street 1:1459 N MAIN ST # 101
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6092
Practice Address - Country:US
Practice Address - Phone:385-600-6365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT139986786009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health