Provider Demographics
NPI:1710216114
Name:CHISHOLM, TIFFANY LYNN (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:LYNN
Last Name:CHISHOLM
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MS
Other - First Name:TIFFANY
Other - Middle Name:LYNN
Other - Last Name:BECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:950 CROSS AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-2002
Mailing Address - Country:US
Mailing Address - Phone:812-273-4640
Mailing Address - Fax:
Practice Address - Street 1:950 CROSS AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-2002
Practice Address - Country:US
Practice Address - Phone:812-273-4640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003695A225X00000X
KYR2926225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist