Healthcare Provider Details

I. General information

NPI: 1356064828
Provider Name (Legal Business Name): TIFFANY SOMERVILLE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 S CENTRAL AVE STE 104
MEDFORD OR
97501-7274
US

IV. Provider business mailing address

328 S CENTRAL AVE STE 104
MEDFORD OR
97501-7274
US

V. Phone/Fax

Practice location:
  • Phone: 541-204-2376
  • Fax: 541-204-2376
Mailing address:
  • Phone: 541-204-2376
  • Fax: 541-204-2376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: