Provider Demographics
NPI:1033688015
Name:QUE-SMITH, TIFFANY MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:QUE-SMITH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2362 LUCRETIA AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95122-3452
Mailing Address - Country:US
Mailing Address - Phone:760-672-0190
Mailing Address - Fax:
Practice Address - Street 1:1210 S BASCOM AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3543
Practice Address - Country:US
Practice Address - Phone:408-559-9556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17954225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist