Provider Demographics
NPI:1013078146
Name:JOHNSON, TIFFANY ANN (OT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:ANN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 PEACHTREE CT
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4616
Mailing Address - Country:US
Mailing Address - Phone:631-467-3700
Mailing Address - Fax:631-467-0928
Practice Address - Street 1:1715 CASTLE GARDENS RD
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1175
Practice Address - Country:US
Practice Address - Phone:607-484-5079
Practice Address - Fax:607-748-1079
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0143551225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist