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NPI Code Detail

MEDICARE: TIFFANY SHAW BCBA

MEDICARE: TIFFANY SHAW BCBA
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
1103K00000XBehavior Analyst1-14-16224IN

General Provider Information

NPI Number : 1518355296
Entity Type Code : Individual
Provider Name (Legal Business Name) : TIFFANY SHAW BCBA
Provider Business Mailing Address
First Line : 4118 N CLINTON ST
Second Line :
City : FORT WAYNE
State : IN
Zip : 46805-1210
Country : US
Telephone Number : 260-373-1050
Fax Number : 260-471-0285
Provider Business Practice Location Address
First Line : 4118 N CLINTON ST
Second Line :
City : FORT WAYNE
State : IN
Zip : 46805-1210
Country : US
Telephone Number : 260-373-1050
Fax Number : 260-471-0285
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/02/2015
Last Update Date : 01/02/2015

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