Provider Demographics
NPI:1457839144
Name:FUSON, TIFFANY ANN (OTR/L, CMT/L)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:FUSON
Suffix:
Gender:F
Credentials:OTR/L, CMT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6032 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:MI
Mailing Address - Zip Code:48458-8536
Mailing Address - Country:US
Mailing Address - Phone:810-730-6816
Mailing Address - Fax:
Practice Address - Street 1:1455 SUNCREST DR
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1151
Practice Address - Country:US
Practice Address - Phone:810-664-8571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
MI5201007069225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty