Provider Demographics
NPI:1679888366
Name:CORDOVA, TIFFANY CRYSTAL
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:CRYSTAL
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24934 FIR GROVE LN
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:OR
Mailing Address - Zip Code:97437-9751
Mailing Address - Country:US
Mailing Address - Phone:541-234-3255
Mailing Address - Fax:541-858-8167
Practice Address - Street 1:24934 FIR GROVE LN
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:OR
Practice Address - Zip Code:97437-9751
Practice Address - Country:US
Practice Address - Phone:541-234-3255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500681069Medicaid