Provider Demographics
NPI:1417171687
Name:FOX, TIFFANY DENISE (OT-A)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DENISE
Last Name:FOX
Suffix:
Gender:F
Credentials:OT-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653
Mailing Address - Country:US
Mailing Address - Phone:870-265-3950
Mailing Address - Fax:870-265-2525
Practice Address - Street 1:316 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653
Practice Address - Country:US
Practice Address - Phone:870-265-3950
Practice Address - Fax:870-265-2525
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTA386174400000X, 224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149514721Medicaid