Provider Demographics
NPI:1992976955
Name:TIFINI A. ROBERTS, PSY.D., LLC
Entity type:Organization
Organization Name:TIFINI A. ROBERTS, PSY.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFINI
Authorized Official - Middle Name:AUTUMN
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:417-886-8540
Mailing Address - Street 1:2146 W CHESTERFIELD BLVD
Mailing Address - Street 2:STE. E202
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-8650
Mailing Address - Country:US
Mailing Address - Phone:417-886-8540
Mailing Address - Fax:417-886-8560
Practice Address - Street 1:2146 W CHESTERFIELD BLVD
Practice Address - Street 2:STE. E202
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-8650
Practice Address - Country:US
Practice Address - Phone:417-886-8540
Practice Address - Fax:417-886-8560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007015271103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497543900Medicaid