Provider Demographics
NPI:1356956585
Name:DEROSIER, TIFFANY NICOLE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:DEROSIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11303 WILSHIRE BLVD BLDG 116
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5069
Mailing Address - Country:US
Mailing Address - Phone:109-144-0453
Mailing Address - Fax:
Practice Address - Street 1:11303 WILSHIRE BLVD BLDG 116
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5069
Practice Address - Country:US
Practice Address - Phone:310-914-4045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner