MEDICARE: TIFFANY ALICE DAWSON PSYD

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	106H00000X	Marriage & Family Therapist	IMF45566	CA
2	103TC0700X	Clinical Psychologist	PSY26763	CA

General Provider Information

NPI Number	:	1760516496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY ALICE DAWSON PSYD

Provider Business Mailing Address
First Line	:	901 W VICTORIA ST STE F&G
Second Line	:
City	:	COMPTON
State	:	CA
Zip	:	90220-5807
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 W VICTORIA ST STE F&G
Second Line	:
City	:	COMPTON
State	:	CA
Zip	:	90220-5807
Country	:	US
Telephone Number	:	310-669-9510
Fax Number	:

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

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	11/25/2020

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