Provider Demographics
NPI:1871235192
Name:JOHNSON, TIFFANY M (COTA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 TROUVILLE RD
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-3002
Mailing Address - Country:US
Mailing Address - Phone:516-439-9008
Mailing Address - Fax:
Practice Address - Street 1:240 TROUVILLE RD
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-3002
Practice Address - Country:US
Practice Address - Phone:516-439-9008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01065601224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant