Provider Demographics
NPI:1407155807
Name:HOMANT, TIFFANY LEEANN (OT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LEEANN
Last Name:HOMANT
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1256 FAIRWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-9489
Mailing Address - Country:US
Mailing Address - Phone:231-944-2146
Mailing Address - Fax:
Practice Address - Street 1:1650 BARLOW ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-4721
Practice Address - Country:US
Practice Address - Phone:231-941-3100
Practice Address - Fax:231-922-0382
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI43-2035142OtherTAX ID