Provider Demographics
NPI:1619552544
Name:BRUNDIDGE, TIFFANY KRISTINA (COTA/L)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:KRISTINA
Last Name:BRUNDIDGE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 N KINGS HWY APT 352
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22303-2920
Mailing Address - Country:US
Mailing Address - Phone:706-483-5203
Mailing Address - Fax:
Practice Address - Street 1:6200 N KINGS HWY APT 352
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22303-2920
Practice Address - Country:US
Practice Address - Phone:706-483-5203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02944224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant