Provider Demographics
NPI:1487127791
Name:ALLY, TIFFANY LAUREN
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LAUREN
Last Name:ALLY
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 1:5473 PEBBLE BEACH DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-1216
Mailing Address - Country:US
Mailing Address - Phone:863-640-8791
Mailing Address - Fax:
Practice Address - Street 1:2044 BROKEN ARROW TRL N
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3704
Practice Address - Country:US
Practice Address - Phone:863-640-8791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW233481041C0700X
253J00000X, 3747P1801X
FL17546104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No253J00000XAgenciesFoster Care Agency
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010816500Medicaid