Provider Demographics
NPI:1114212511
Name:BLACK, TIFFANY B (PC)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:B
Last Name:BLACK
Suffix:
Gender:F
Credentials:PC
Other - Prefix:MS
Other - First Name:TIFFANY
Other - Middle Name:B
Other - Last Name:WHEELER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1856 CEDAR HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-4178
Mailing Address - Country:US
Mailing Address - Phone:740-687-4500
Mailing Address - Fax:740-687-4595
Practice Address - Street 1:1856 CEDAR HILL ROAD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-4178
Practice Address - Country:US
Practice Address - Phone:740-687-4500
Practice Address - Fax:740-687-4595
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0600202101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health