Basic Information
| Provider Information | |||||||||
| NPI: | 1023498649 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BORN | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 E SAINT JOSEPH ST | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543012241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457226 | ||||||||
| FaxNumber: | 9204457229 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 REDBIRD CIR STE 100 | ||||||||
| Address2: | |||||||||
| City: | DE PERE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541157978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203386830 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2015 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 3514-57 | WI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.