MEDICARE: TIFFANY GAIL HARRIS

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	103TC2200X	Clinical Child & Adolescent Psychologist	P.08829	OH
2	106S00000X	Behavior Technician	RBT-21-173834	MS
3	101YM0800X	Mental Health Counselor	13487	NE

General Provider Information

NPI Number	:	1770154817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY GAIL HARRIS

Provider Business Mailing Address
First Line	:	4315 IVY POINTE BLVD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45245-1767
Country	:	US
Telephone Number	:	513-636-9504
Fax Number	:

Provider Business Practice Location Address
First Line	:	4315 IVY POINTE BLVD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45245-1767
Country	:	US
Telephone Number	:	513-636-9504
Fax Number	:

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

Provider Enumeration Date	:	07/09/2021
Last Update Date	:	09/16/2025

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