Healthcare Provider Details

I. General information

NPI: 1689553075
Provider Name (Legal Business Name): TIFFANY STATHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 W WHITMAN ST
POCATELLO ID
83204-4203
US

IV. Provider business mailing address

737 W WHITMAN ST
POCATELLO ID
83204-4203
US

V. Phone/Fax

Practice location:
  • Phone: 208-241-6456
  • Fax:
Mailing address:
  • Phone: 208-241-6456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: