Provider Demographics
NPI:1972043933
Name:SEAL, TIFFANY ANN (PTA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:SEAL
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 1:10470 DIBERVILLE BLVD STE H
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-2419
Mailing Address - Country:US
Mailing Address - Phone:228-280-8120
Mailing Address - Fax:228-280-8121
Practice Address - Street 1:10470 DIBERVILLE BLVD STE H
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-2419
Practice Address - Country:US
Practice Address - Phone:228-280-8120
Practice Address - Fax:228-280-8121
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA6088225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant