Provider Demographics
NPI:1760107718
Name:LUMAYOG, TIFFANY CLAIRE VILLARTA
Entity Type:Individual
Prefix:
First Name:TIFFANY CLAIRE
Middle Name:VILLARTA
Last Name:LUMAYOG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 E JOPPA RD
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5404
Mailing Address - Country:US
Mailing Address - Phone:410-828-9494
Mailing Address - Fax:
Practice Address - Street 1:509 E JOPPA RD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-5404
Practice Address - Country:US
Practice Address - Phone:410-828-9494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02677225XG0600X, 224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1559696656OtherMANAGED-CARE
MD1559696656Medicaid