Provider Demographics
NPI:1194313262
Name:TIFFANY MCBRIDE
Entity type:Organization
Organization Name:TIFFANY MCBRIDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LEAD THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCBRIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-979-0369
Mailing Address - Street 1:2103 E WASHINGTON ST BLDG 3
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4310
Mailing Address - Country:US
Mailing Address - Phone:217-979-0369
Mailing Address - Fax:
Practice Address - Street 1:2103 E WASHINGTON ST BLDG 3
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4310
Practice Address - Country:US
Practice Address - Phone:217-979-0369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty