Healthcare Provider Details

I. General information

NPI: 1134674799
Provider Name (Legal Business Name): TIFFANEY BOULWARE MFTI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5870 ARLINGTON AVE.
RIVERSIDE CA
92504
US

IV. Provider business mailing address

4022 MCARTHUR RD
RIVERSIDE CA
92503-3848
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-6596
  • Fax:
Mailing address:
  • Phone: 562-900-0588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF101414
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: