Provider Demographics
NPI:1386098515
Name:JOHNSON, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:JOHNSON
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 1:2814 15TH PL
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-3108
Mailing Address - Country:US
Mailing Address - Phone:503-367-6152
Mailing Address - Fax:
Practice Address - Street 1:2814 15TH PL
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-3108
Practice Address - Country:US
Practice Address - Phone:503-367-6152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-B-10243335103K00000X
MI7401002844103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst