Provider Demographics
NPI:1790063691
Name:LINVILLE, TIFFANY NICOLA (MPT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLA
Last Name:LINVILLE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2459 FEDERAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-2915
Mailing Address - Country:US
Mailing Address - Phone:310-994-2376
Mailing Address - Fax:
Practice Address - Street 1:3018 E COLORADO BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3840
Practice Address - Country:US
Practice Address - Phone:616-449-3900
Practice Address - Fax:626-449-4505
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT379772251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT37977OtherSTATE OF CALIFORNIA
CAPT37977OtherSTATE OF CALIFORNIA