Provider Demographics
NPI:1194439463
Name:GORDON, TIFFANY TALLEY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:TALLEY
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 COURTNEY LAKES CIR APT 204
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-2431
Mailing Address - Country:US
Mailing Address - Phone:561-459-7107
Mailing Address - Fax:
Practice Address - Street 1:12161 KEN ADAMS WAY STE 212
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-3192
Practice Address - Country:US
Practice Address - Phone:561-459-7107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health