Provider Demographics
NPI:1861862922
Name:GARY, TIFFANY (ATC, LAT,)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:GARY
Suffix:
Gender:F
Credentials:ATC, LAT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12500 OLD HAMMOND HWY APT N1
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-1094
Mailing Address - Country:US
Mailing Address - Phone:337-349-4927
Mailing Address - Fax:
Practice Address - Street 1:1221 S CLEARVIEW PKWY
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:LA
Practice Address - Zip Code:70121-1011
Practice Address - Country:US
Practice Address - Phone:337-349-4927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAATH.J002962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer