Healthcare Provider Details

I. General information

NPI: 1639612393
Provider Name (Legal Business Name): TIFFANY THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 SW FRAZER AVE STE 282
PENDLETON OR
97801-0048
US

IV. Provider business mailing address

702 SUNSET DR
ONTARIO OR
97914-3121
US

V. Phone/Fax

Practice location:
  • Phone: 541-278-6330
  • Fax: 541-278-5419
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: