Healthcare Provider Details

I. General information

NPI: 1083114698
Provider Name (Legal Business Name): TIFFANY MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 LAKE HOLLINGSWORTH DR
LAKELAND FL
33803-2364
US

IV. Provider business mailing address

PO BOX 93374
LAKELAND FL
33804-3374
US

V. Phone/Fax

Practice location:
  • Phone: 863-665-7300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-49175
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: