Healthcare Provider Details

I. General information

NPI: 1962940130
Provider Name (Legal Business Name): TIFFANY WALEHWA M.A., P.L.P.C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1167 CORPORATE LAKE DR
SAINT LOUIS MO
63132-1716
US

IV. Provider business mailing address

3109 MAYBELLE DR
SAINT LOUIS MO
63121-4242
US

V. Phone/Fax

Practice location:
  • Phone: 314-968-2350
  • Fax:
Mailing address:
  • Phone: 314-709-0543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2015043624
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: