Healthcare Provider Details

I. General information

NPI: 1518861582
Provider Name (Legal Business Name): TIFFANY R LO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1176 CYPRESS GLEN CIR
KISSIMMEE FL
34741-7560
US

IV. Provider business mailing address

9546 CALLE DIAZ WAY CONDOMINIO ASTRALIS APT. 614
ISLA VERDE PR
00979
US

V. Phone/Fax

Practice location:
  • Phone: 407-201-2103
  • Fax:
Mailing address:
  • Phone: 787-400-4142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: