Provider Demographics
NPI:1114290723
Name:KELLETT, TIFFANY L (DPT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:L
Last Name:KELLETT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8073 WASHINGTON VILLAGE DRIVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-1847
Mailing Address - Country:US
Mailing Address - Phone:937-813-8052
Mailing Address - Fax:937-813-8056
Practice Address - Street 1:4451 MAHONING AVE NW STE A
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-1977
Practice Address - Country:US
Practice Address - Phone:330-372-0207
Practice Address - Fax:330-372-0206
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT013332225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist