Provider Demographics
NPI:1689918930
Name:RICHARDSON, TIFFANY LEVONNE (MOTR/L)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LEVONNE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11572 PARK TRAILS ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-5720
Mailing Address - Country:US
Mailing Address - Phone:909-645-8402
Mailing Address - Fax:
Practice Address - Street 1:550 N MONTEREY AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-3318
Practice Address - Country:US
Practice Address - Phone:909-391-0333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8043225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8043OtherCALIFORNIA BOARD OF OCCUPATIONAL THERAPY