Healthcare Provider Details

I. General information

NPI: 1144414327
Provider Name (Legal Business Name): TIFFINY DONNALEE WHITEHEAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NE 7TH ST
GRESHAM OR
97030-5604
US

IV. Provider business mailing address

400 NE 7TH ST
GRESHAM OR
97030-5604
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-5455
  • Fax:
Mailing address:
  • Phone: 503-661-5455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: