=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609594068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY MCMURRAY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2022
-----------------------------------------------------
Last Update Date | 08/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1205 S DAKOTA ST
-----------------------------------------------------
City | GREEN RIVER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82935-5821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-657-7249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1205 S DAKOTA ST
-----------------------------------------------------
City | GREEN RIVER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82935-5821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-657-7249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------