Provider Demographics
NPI:1366928525
Name:PERRY, TIFFANAY MICHELLE (LMFT)
Entity type:Individual
Prefix:
First Name:TIFFANAY
Middle Name:MICHELLE
Last Name:PERRY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 KENDALL DR APT 1224
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-5858
Mailing Address - Country:US
Mailing Address - Phone:909-559-0743
Mailing Address - Fax:
Practice Address - Street 1:850 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5230
Practice Address - Country:US
Practice Address - Phone:909-559-0743
Practice Address - Fax:951-684-7503
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107133106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist