Provider Demographics
NPI:1497103543
Name:MALLICK, TIFFANY JOY (ATC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:JOY
Last Name:MALLICK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5092 OAK BEND DR
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-1512
Mailing Address - Country:US
Mailing Address - Phone:909-973-7888
Mailing Address - Fax:
Practice Address - Street 1:5092 OAK BEND DR
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-1512
Practice Address - Country:US
Practice Address - Phone:909-973-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist