Provider Demographics
NPI:1255422390
Name:WAX, TIFFANNI (COTA/L)
Entity type:Individual
Prefix:
First Name:TIFFANNI
Middle Name:
Last Name:WAX
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 1:683 STATE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4660
Mailing Address - Country:US
Mailing Address - Phone:701-483-9400
Mailing Address - Fax:701-483-9398
Practice Address - Street 1:683 STATE AVE STE B
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4660
Practice Address - Country:US
Practice Address - Phone:701-483-9400
Practice Address - Fax:701-483-9398
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND841224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant