MEDICARE: TIFFANY DEBORAH PARK M.A., CCC-SLP

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	235Z00000X	Speech-Language Pathologist	32937	CA

General Provider Information

NPI Number	:	1790408870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY DEBORAH PARK M.A., CCC-SLP

Provider Business Mailing Address
First Line	:	2700 UNIVERSITY AVE W APT 145
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55114-1752
Country	:	US
Telephone Number	:	714-313-7863
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 UNIVERSITY AVE W APT 145
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55114-1752
Country	:	US
Telephone Number	:	714-313-7863
Fax Number	:

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

Provider Enumeration Date	:	09/22/2022
Last Update Date	:	09/22/2022

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Directions to “ TIFFANY DEBORAH PARK M.A., CCC-SLP” Practice Location

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