Healthcare Provider Details

I. General information

NPI: 1275120271
Provider Name (Legal Business Name): TIFFANY EVE VASTARDIS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2020
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6410 SW 57TH ST
DAVIE FL
33314-7106
US

IV. Provider business mailing address

5510 SW 44TH TER
FORT LAUDERDALE FL
33314-6720
US

V. Phone/Fax

Practice location:
  • Phone: 954-326-2795
  • Fax:
Mailing address:
  • Phone: 954-326-2795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH20180
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: