Provider Demographics
NPI:1235680232
Name:WYMORE, TIFFANY NICOLE (MA,PLPC)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:NICOLE
Last Name:WYMORE
Suffix:
Gender:F
Credentials:MA,PLPC
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:NICOLE
Other - Last Name:PELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:623 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-4021
Mailing Address - Country:US
Mailing Address - Phone:573-701-2872
Mailing Address - Fax:
Practice Address - Street 1:9666 OLIVE BLVD STE 370
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3025
Practice Address - Country:US
Practice Address - Phone:573-701-2872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016034260101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health