Provider Demographics
NPI:1013399922
Name:TIFA, IVORY (OTR/L)
Entity Type:Individual
Prefix:
First Name:IVORY
Middle Name:
Last Name:TIFA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:IVORY
Other - Middle Name:
Other - Last Name:FLYNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1476 AUGUSTA ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-7190
Mailing Address - Country:US
Mailing Address - Phone:917-406-4435
Mailing Address - Fax:
Practice Address - Street 1:1476 AUGUSTA ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-7190
Practice Address - Country:US
Practice Address - Phone:917-406-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9727225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics