Provider Demographics
NPI:1780015602
Name:FOGARTY, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:FOGARTY
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 1:403 E BROAD ST
Mailing Address - Street 2:APARTMENT 5
Mailing Address - City:TAMAQUA
Mailing Address - State:PA
Mailing Address - Zip Code:18252-2131
Mailing Address - Country:US
Mailing Address - Phone:570-436-0301
Mailing Address - Fax:
Practice Address - Street 1:401 HAZLE TOWNSHIP BLVD
Practice Address - Street 2:403 HAZLE TOWNSHIP BLVD
Practice Address - City:HAZLE TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18202-9661
Practice Address - Country:US
Practice Address - Phone:570-454-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE009137225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant