Healthcare Provider Details

I. General information

NPI: 1093102444
Provider Name (Legal Business Name): TIFFANY LYNN IVERSON MFT INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 FIRST STREET
NAPA CA
94559
US

IV. Provider business mailing address

PO BOX 3651
NAPA CA
94558-0365
US

V. Phone/Fax

Practice location:
  • Phone: 707-255-1855
  • Fax:
Mailing address:
  • Phone: 707-255-1855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: