Provider Demographics
NPI:1033689815
Name:MITCHELL, TIFFANY ROSE (PTA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ROSE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 COUNTY ROAD 425
Mailing Address - Street 2:
Mailing Address - City:MCCOY
Mailing Address - State:TX
Mailing Address - Zip Code:78113-3374
Mailing Address - Country:US
Mailing Address - Phone:830-570-3747
Mailing Address - Fax:
Practice Address - Street 1:1504 TX-97E
Practice Address - Street 2:
Practice Address - City:JOURDANTON
Practice Address - State:TX
Practice Address - Zip Code:78026
Practice Address - Country:US
Practice Address - Phone:830-769-3531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2062041225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant