Provider Demographics
NPI:1962089680
Name:MOSES, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MOSES
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 1:14840 SHEPARD DR
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-2467
Mailing Address - Country:US
Mailing Address - Phone:708-250-6830
Mailing Address - Fax:
Practice Address - Street 1:14840 SHEPARD DR
Practice Address - Street 2:
Practice Address - City:DOLTON
Practice Address - State:IL
Practice Address - Zip Code:60419-2467
Practice Address - Country:US
Practice Address - Phone:708-250-6830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician