Provider Demographics
NPI:1407925746
Name:BOULWARE, TIFFANY (DPT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4780 N JOSEY LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4615
Mailing Address - Country:US
Mailing Address - Phone:972-492-1334
Mailing Address - Fax:919-424-5085
Practice Address - Street 1:1000 N PRESTON RD STE 50
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-8859
Practice Address - Country:US
Practice Address - Phone:972-347-9756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2023-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1145779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1145779OtherSTATE OF TEXAS