Provider Demographics
NPI:1659787539
Name:SIMON, TIFFANY N (DPT)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:N
Last Name:SIMON
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 1:307 ASHTIN WAY
Mailing Address - Street 2:
Mailing Address - City:HORTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54944-1020
Mailing Address - Country:US
Mailing Address - Phone:937-286-2748
Mailing Address - Fax:
Practice Address - Street 1:307 ASHTIN WAY
Practice Address - Street 2:
Practice Address - City:HORTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54944-1020
Practice Address - Country:US
Practice Address - Phone:937-286-2748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12787-24225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP01377300OtherRR MEDICARE
WIP01377300OtherRR MEDICARE