Provider Demographics
NPI:1598268120
Name:DECKER, TIFFANY BLAIR (COTA)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:BLAIR
Last Name:DECKER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 WESTPORT PKWY STE 1300
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-5316
Mailing Address - Country:US
Mailing Address - Phone:817-773-6841
Mailing Address - Fax:
Practice Address - Street 1:2400 WESTPORT PKWY STE 1300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-5316
Practice Address - Country:US
Practice Address - Phone:817-773-6841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213560224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant