Healthcare Provider Details

I. General information

NPI: 1235907486
Provider Name (Legal Business Name): TIFFANY DESIRE VERNON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13301 N MERIDIAN AVE STE 100
OKLAHOMA CITY OK
73120-8357
US

IV. Provider business mailing address

13301 N MERIDIAN AVE STE 100
OKLAHOMA CITY OK
73120-8357
US

V. Phone/Fax

Practice location:
  • Phone: 405-310-3262
  • Fax: 405-873-6364
Mailing address:
  • Phone: 405-310-3262
  • Fax: 405-873-6364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8365
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8365
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: