MEDICARE: TIFFANY NICOLE ROBINSON ST MS

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	235Z00000X	Speech-Language Pathologist	146.008971	IL
2	235Z00000X	Speech-Language Pathologist	113778	TX

General Provider Information

NPI Number	:	1710075791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY NICOLE ROBINSON ST MS

Provider Business Mailing Address
First Line	:	5942 KATHRYN LN
Second Line	:
City	:	MATTESON
State	:	IL
Zip	:	60443-1172
Country	:	US
Telephone Number	:	708-724-5112
Fax Number	:

Provider Business Practice Location Address
First Line	:	4315 HOPKINS AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75209-3026
Country	:	US
Telephone Number	:	214-358-3131
Fax Number	:

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

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	09/19/2018

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