Provider Demographics
NPI:1588320535
Name:BEATTY, TIFFANI JEAN
Entity type:Individual
Prefix:
First Name:TIFFANI
Middle Name:JEAN
Last Name:BEATTY
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 1:820 21ST ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:MN
Mailing Address - Zip Code:55055-1525
Mailing Address - Country:US
Mailing Address - Phone:651-300-8070
Mailing Address - Fax:
Practice Address - Street 1:731 BIELENBERG DR # 102-104
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1700
Practice Address - Country:US
Practice Address - Phone:612-445-8326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician