Provider Demographics
NPI:1194458703
Name:SAM, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:SAM
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 1:2730 UNIVERSITY BLVD W STE 310
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:MD
Mailing Address - Zip Code:20902-1990
Mailing Address - Country:US
Mailing Address - Phone:301-942-0442
Mailing Address - Fax:301-576-7421
Practice Address - Street 1:14995 SHADY GROVE RD STE 250
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-8727
Practice Address - Country:US
Practice Address - Phone:301-942-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD29136225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist