Healthcare Provider Details

I. General information

NPI: 1104453836
Provider Name (Legal Business Name): TIFFANY SHELL FLIPPEN LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY SHELL SALAMI

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 E. ROOSEVELT AVE.
GRANTS NM
87020
US

IV. Provider business mailing address

1120 INWOOD AVE
GRANTS NM
87020
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-5211
  • Fax: 505-287-6737
Mailing address:
  • Phone: 505-409-3945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: