Provider Demographics
NPI:1699964585
Name:ELLIS, TIFFANY RENEE'
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:RENEE'
Last Name:ELLIS
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 1:1120 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-3451
Mailing Address - Country:US
Mailing Address - Phone:530-573-3386
Mailing Address - Fax:530-543-6697
Practice Address - Street 1:1120 3RD ST
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3451
Practice Address - Country:US
Practice Address - Phone:530-573-3386
Practice Address - Fax:530-543-6697
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)