Provider Demographics
NPI:1255168431
Name:KEENE, TIFFANY (COTA/L)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:KEENE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1158
Mailing Address - Street 2:
Mailing Address - City:VANSANT
Mailing Address - State:VA
Mailing Address - Zip Code:24656-1158
Mailing Address - Country:US
Mailing Address - Phone:276-935-9205
Mailing Address - Fax:276-451-7836
Practice Address - Street 1:1190 ANCHORAGE CIR
Practice Address - Street 2:
Practice Address - City:VANSANT
Practice Address - State:VA
Practice Address - Zip Code:24656-7019
Practice Address - Country:US
Practice Address - Phone:276-935-9205
Practice Address - Fax:276-451-7836
Is Sole Proprietor?:No
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002064224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant