Provider Demographics
NPI:1518206655
Name:ROBERTS, TIFFANY H (OT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:H
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4914
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:3100 CLAY ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-4075
Practice Address - Country:US
Practice Address - Phone:270-442-6884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-09
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY170673225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist