MEDICARE: TIFFANY BLUE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	2007019824	MO

General Provider Information

NPI Number	:	1225213721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY BLUE

Provider Business Mailing Address
First Line	:	4326 W PINE BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-2206
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4326 W PINE BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-2206
Country	:	US
Telephone Number	:	314-479-9121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2008
Last Update Date	:	01/02/2008

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Directions to “ TIFFANY BLUE ” Practice Location

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