Provider Demographics
NPI:1033463237
Name:WILSON, TIFFANY (LMT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2134 SANDY DR
Mailing Address - Street 2:SUITE 9
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-2292
Mailing Address - Country:US
Mailing Address - Phone:814-234-8900
Mailing Address - Fax:
Practice Address - Street 1:2134 SANDY DR
Practice Address - Street 2:SUITE 9
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-2292
Practice Address - Country:US
Practice Address - Phone:814-234-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG002883225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist