Healthcare Provider Details

I. General information

NPI: 1770154817
Provider Name (Legal Business Name): TIFFANY GAIL HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 IVY POINTE BLVD
CINCINNATI OH
45245-1767
US

IV. Provider business mailing address

4315 IVY POINTE BLVD
CINCINNATI OH
45245-1767
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-9504
  • Fax:
Mailing address:
  • Phone: 513-636-9504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13487
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberP.08829
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-173834
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: