Provider Demographics
NPI:1922745751
Name:LIST, TIFFANY DESIREA (LMT, PTA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DESIREA
Last Name:LIST
Suffix:
Gender:F
Credentials:LMT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 ABALONE RD NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-2966
Mailing Address - Country:US
Mailing Address - Phone:321-759-3555
Mailing Address - Fax:
Practice Address - Street 1:1049 EBER BLVD STE 103
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-8767
Practice Address - Country:US
Practice Address - Phone:321-759-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA72585225700000X
FLPTA29516225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist