=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184011488
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY TELESCA LPC-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2015
-----------------------------------------------------
Last Update Date | 04/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 N 5TH ST
-----------------------------------------------------
City | ALPINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79830-4602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-294-4153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2464
-----------------------------------------------------
City | ALPINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79831-2464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-294-4153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 70289
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------