Provider Demographics
NPI:1558655498
Name:CLARK, TIFFANY DAWN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:DAWN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3951 ARROWHEAD DR
Mailing Address - Street 2:UNIT C
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7257
Mailing Address - Country:US
Mailing Address - Phone:541-621-2786
Mailing Address - Fax:
Practice Address - Street 1:3951 ARROWHEAD DR
Practice Address - Street 2:UNIT C
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7257
Practice Address - Country:US
Practice Address - Phone:541-621-2786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16488225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist