Provider Demographics
NPI:1306040340
Name:GOLD, TIFFANY D (OTR, MHA)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:D
Last Name:GOLD
Suffix:
Gender:F
Credentials:OTR, MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13119 WILLOWTHORN LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-4855
Mailing Address - Country:US
Mailing Address - Phone:210-696-0004
Mailing Address - Fax:
Practice Address - Street 1:855 E BASSE RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-1890
Practice Address - Country:US
Practice Address - Phone:210-824-6280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111355225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX675542Medicare ID - Type Unspecified