Provider Demographics
NPI:1841794914
Name:WALLACE, TIFFANY (COTA/L)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1271 STATIONSIDE DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34787-8944
Mailing Address - Country:US
Mailing Address - Phone:772-971-1201
Mailing Address - Fax:
Practice Address - Street 1:1271 STATIONSIDE DR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:FL
Practice Address - Zip Code:34787-8944
Practice Address - Country:US
Practice Address - Phone:772-971-1201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant