Provider Demographics
NPI:1699920421
Name:LOCKHART, TIFFANY (TY) (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TIFFANY (TY)
Middle Name:
Last Name:LOCKHART
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:KERSTETTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:2355 STATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4541
Mailing Address - Country:US
Mailing Address - Phone:541-203-0893
Mailing Address - Fax:
Practice Address - Street 1:HOME & COMMUNITY LOCATIONS
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1207
Practice Address - Country:US
Practice Address - Phone:541-203-0893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16835235Z00000X
WALL60023213235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR85-3915764OtherPEAK COMMUNICATION THERAPY
OR85-3915764OtherPEAK COMMUNICATION THERAPY