Provider Demographics
NPI:1871845727
Name:PICKETT, TIFFANIE MICHELLE (PTA)
Entity Type:Individual
Prefix:MS
First Name:TIFFANIE
Middle Name:MICHELLE
Last Name:PICKETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 WREN WAY
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-9588
Mailing Address - Country:US
Mailing Address - Phone:765-623-6145
Mailing Address - Fax:
Practice Address - Street 1:1411 W COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-5249
Practice Address - Country:US
Practice Address - Phone:317-886-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004505A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant