Provider Demographics
NPI:1467644476
Name:MARTIN, TIFFANY JOY (OTR/L)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:JOY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 135
Mailing Address - Street 2:36 CALAIS ROAD
Mailing Address - City:WORCESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05682-0135
Mailing Address - Country:US
Mailing Address - Phone:678-548-0171
Mailing Address - Fax:
Practice Address - Street 1:317 AUBURN ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-5209
Practice Address - Country:US
Practice Address - Phone:415-456-4409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT8461171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor