Provider Demographics
NPI:1194068890
Name:DOMINEY, TIFFANY A (LPCA)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:A
Last Name:DOMINEY
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 NEW START RD
Mailing Address - Street 2:
Mailing Address - City:BRONSTON
Mailing Address - State:KY
Mailing Address - Zip Code:42518-8572
Mailing Address - Country:US
Mailing Address - Phone:606-561-5797
Mailing Address - Fax:606-561-9928
Practice Address - Street 1:500 NEW START RD
Practice Address - Street 2:
Practice Address - City:BRONSTON
Practice Address - State:KY
Practice Address - Zip Code:42518-8572
Practice Address - Country:US
Practice Address - Phone:606-561-5797
Practice Address - Fax:606-561-9928
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1561101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY127314Medicaid