Provider Demographics
NPI:1588202485
Name:STARKS, TIFFANY MICHELLE (LMT)
Entity Type:Individual
Prefix:MISS
First Name:TIFFANY
Middle Name:MICHELLE
Last Name:STARKS
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 1:600 COUNTRY CLUB DR APT 72
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-4145
Mailing Address - Country:US
Mailing Address - Phone:931-561-4569
Mailing Address - Fax:
Practice Address - Street 1:757 E LEWIS AND CLARK PKWY STE 342
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47131-6078
Practice Address - Country:US
Practice Address - Phone:931-561-4569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2020-10-21
Deactivation Date:2020-09-24
Deactivation Code:
Reactivation Date:2020-10-21
Provider Licenses
StateLicense IDTaxonomies
INMT21906841225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist