Provider Demographics
NPI:1992401962
Name:CORRELL, TIFFANY NICOLE
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:NICOLE
Last Name:CORRELL
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 1:6222 I-10 STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201
Mailing Address - Country:US
Mailing Address - Phone:210-447-0039
Mailing Address - Fax:
Practice Address - Street 1:21755 I45 N BLDG 8
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77388-3621
Practice Address - Country:US
Practice Address - Phone:832-501-0833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician