Healthcare Provider Details

I. General information

NPI: 1104300342
Provider Name (Legal Business Name): TIFFANY FARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 DORSEY LN
LOUISVILLE KY
40223-2612
US

IV. Provider business mailing address

1015 DORSEY LN
LOUISVILLE KY
40223-2612
US

V. Phone/Fax

Practice location:
  • Phone: 502-245-1576
  • Fax:
Mailing address:
  • Phone: 502-245-1576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7010
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: