Provider Demographics
NPI:1023498649
Name:BORN, TIFFANY LYNN (PHD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNN
Last Name:BORN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E SAINT JOSEPH ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2241
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:555 REDBIRD CIR STE 100
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-7978
Practice Address - Country:US
Practice Address - Phone:920-338-6830
Practice Address - Fax:920-445-7289
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3514-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist