Provider Demographics
NPI:1043677792
Name:CAMILLUCCI, TIFFANY (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:
Last Name:CAMILLUCCI
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 BALTIC RD
Mailing Address - Street 2:
Mailing Address - City:NORTH FRANKLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06254-1406
Mailing Address - Country:US
Mailing Address - Phone:860-639-1437
Mailing Address - Fax:
Practice Address - Street 1:5 RICHARD BROWN DR
Practice Address - Street 2:
Practice Address - City:UNCASVILLE
Practice Address - State:CT
Practice Address - Zip Code:06382-1141
Practice Address - Country:US
Practice Address - Phone:860-848-8466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001636224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant