Provider Demographics
NPI:1821702200
Name:PETRY, TIFFANY ROSE (LAC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ROSE
Last Name:PETRY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3155 PORTLAND ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-5140
Mailing Address - Country:US
Mailing Address - Phone:541-968-3395
Mailing Address - Fax:
Practice Address - Street 1:1725 PEARL ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4118
Practice Address - Country:US
Practice Address - Phone:541-968-3395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LMT-12041225700000X
ORAC212915171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist