Provider Demographics
NPI:1588916779
Name:PESTOTNIK, TIFFANI
Entity type:Individual
Prefix:
First Name:TIFFANI
Middle Name:
Last Name:PESTOTNIK
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 1:847 PARKCENTRE WAY
Mailing Address - Street 2:SUITE #4
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-1792
Mailing Address - Country:US
Mailing Address - Phone:208-467-2673
Mailing Address - Fax:208-467-4150
Practice Address - Street 1:847 PARKCENTRE WAY
Practice Address - Street 2:SUITE #4
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1792
Practice Address - Country:US
Practice Address - Phone:208-467-2673
Practice Address - Fax:208-467-4150
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID358811041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical