Provider Demographics
NPI:1639183999
Name:CROFT, TIFFANY EDNA (LMT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:EDNA
Last Name:CROFT
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 1:405 HEARD DR
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-6746
Mailing Address - Country:US
Mailing Address - Phone:706-265-0124
Mailing Address - Fax:
Practice Address - Street 1:309 PIRKLE FERRY RD STE A200
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2546
Practice Address - Country:US
Practice Address - Phone:470-839-5867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT003275225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1065920OtherASHN