Provider Demographics
NPI:1356663595
Name:THERIAULT, TIFFANY A (MT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:A
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 TOWN CTR STE 2001
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-1116
Mailing Address - Country:US
Mailing Address - Phone:248-352-0314
Mailing Address - Fax:248-281-0759
Practice Address - Street 1:16801 NEWBURGH RD STE 114
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1606
Practice Address - Country:US
Practice Address - Phone:248-910-3644
Practice Address - Fax:248-773-7035
Is Sole Proprietor?:No
Enumeration Date:2010-02-15
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist