Provider Demographics
NPI:1710227178
Name:DEAN, TIFFANY (OTR)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:DEAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 NE LOOP 820 BUSINESS TOWER 1
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053
Mailing Address - Country:US
Mailing Address - Phone:817-789-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:5225 S LOOP 289
Practice Address - Street 2:SUITE 210
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-1363
Practice Address - Country:US
Practice Address - Phone:806-780-4180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114574225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX331042299Medicaid