Provider Demographics
NPI:1578120622
Name:STEVENS, TIFFANY NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19556 SAGER LOOP
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-9810
Mailing Address - Country:US
Mailing Address - Phone:541-610-5049
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 264 191 SOUTH
Practice Address - Street 2:SAGE MEMORIAL HOSPITAL
Practice Address - City:GANDO
Practice Address - State:AZ
Practice Address - Zip Code:86505
Practice Address - Country:US
Practice Address - Phone:541-610-5049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCP001146T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist