Provider Demographics
NPI:1215642129
Name:ROBERTS, TIFFANEE SHANICE
Entity type:Individual
Prefix:
First Name:TIFFANEE
Middle Name:SHANICE
Last Name:ROBERTS
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 1:18215 FOOTHILL BLVD APT 97
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-8513
Mailing Address - Country:US
Mailing Address - Phone:909-317-7606
Mailing Address - Fax:
Practice Address - Street 1:18215 FOOTHILL BLVD APT 97
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-8513
Practice Address - Country:US
Practice Address - Phone:909-317-7606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty