Provider Demographics
NPI:1487991261
Name:POULSEN, TIFFANI LEDEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:TIFFANI
Middle Name:LEDEL
Last Name:POULSEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:TIFFANI
Other - Middle Name:LEDEL
Other - Last Name:EDMUNDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:316 S HUMBOLDT ST
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3338
Mailing Address - Country:US
Mailing Address - Phone:650-393-3134
Mailing Address - Fax:
Practice Address - Street 1:316 S HUMBOLDT ST
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3338
Practice Address - Country:US
Practice Address - Phone:650-393-3134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-13
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22864103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1538458716Medicare UPIN