Provider Demographics
NPI:1194194829
Name:KEOUGH, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:KEOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46555 HARRY BYRD HWY
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-3567
Mailing Address - Country:US
Mailing Address - Phone:703-421-6406
Mailing Address - Fax:703-421-6839
Practice Address - Street 1:46555 HARRY BYRD HWY
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-3567
Practice Address - Country:US
Practice Address - Phone:703-421-6406
Practice Address - Fax:703-421-6839
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23066601342225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant