Provider Demographics
NPI:1760831838
Name:CLARK, TIFFANY LYNEA (MA, OTR/L)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNEA
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7463 S QUAIL CIR APT 313
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80127-4922
Mailing Address - Country:US
Mailing Address - Phone:949-338-0779
Mailing Address - Fax:
Practice Address - Street 1:7463 S QUAIL CIR APT 313
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80127-4922
Practice Address - Country:US
Practice Address - Phone:949-338-0779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0003969225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist