Basic Information
| Provider Information | |||||||||
| NPI: | 1346575388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SYBESMA | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | LYNAE | ||||||||
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| OtherLastName: | BYLSMA | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | LYNAE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1800 TULLY RD | ||||||||
| Address2: | SUITE F | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953502946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095761750 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1800 TULLY RD | ||||||||
| Address2: | SUITE F | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953502946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095761750 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2009 | ||||||||
| LastUpdateDate: | 03/15/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1041C0700X | 32610 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.