Healthcare Provider Details

I. General information

NPI: 1376127126
Provider Name (Legal Business Name): TIFFANY M. BOARDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20411 W 12 MILE RD STE 208
SOUTHFIELD MI
48076-6405
US

IV. Provider business mailing address

1120 CHICAGO BLVD
DETROIT MI
48202-1419
US

V. Phone/Fax

Practice location:
  • Phone: 734-561-4102
  • Fax:
Mailing address:
  • Phone: 734-561-4102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY MICHELLE BOARDS
Title or Position: OWNER / CLINICAL PSYCHOLOGIST
Credential: PHD
Phone: 734-561-4102