MEDICARE: TIFFANY DE LEON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	3584	FL

General Provider Information

NPI Number	:	1386288421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY DE LEON

Provider Business Mailing Address
First Line	:	13735 STEELE CREEK RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28273-6841
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13735 STEELE CREEK RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28273-6841
Country	:	US
Telephone Number	:	704-502-9397
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2019
Last Update Date	:	09/17/2020

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Directions to “ TIFFANY DE LEON ” Practice Location

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