Healthcare Provider Details

I. General information

NPI: 1417708256
Provider Name (Legal Business Name): TIFFANI RAE HOTWAGNER BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2024
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1639 N ALPINE RD
ROCKFORD IL
61107-1449
US

IV. Provider business mailing address

6614 LANTERNE DR
LOVES PARK IL
61111-3526
US

V. Phone/Fax

Practice location:
  • Phone: 815-484-3143
  • Fax:
Mailing address:
  • Phone: 630-701-5249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: