Provider Demographics
NPI:1255581575
Name:RIDEAU, TIFFANY Q
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:Q
Last Name:RIDEAU
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 1:2914 N GLENHAVEN DR APT H2
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-4032
Mailing Address - Country:US
Mailing Address - Phone:405-886-5206
Mailing Address - Fax:405-759-2669
Practice Address - Street 1:2914 N GLENHAVEN DR APT H2
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110
Practice Address - Country:US
Practice Address - Phone:405-886-5206
Practice Address - Fax:405-886-5206
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5525101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200555290AMedicaid