Provider Demographics
NPI:1376885749
Name:TIFFANY, BERNADETTE (PTA, LMT,CFT)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:TIFFANY
Suffix:
Gender:F
Credentials:PTA, LMT,CFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 W D ST
Mailing Address - Street 2:SUITE 100C
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3451
Mailing Address - Country:US
Mailing Address - Phone:719-240-3745
Mailing Address - Fax:719-545-2807
Practice Address - Street 1:126 W D ST
Practice Address - Street 2:SUITE 100C
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3451
Practice Address - Country:US
Practice Address - Phone:719-240-3745
Practice Address - Fax:719-545-2807
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0006224225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist