Provider Demographics
NPI:1700243615
Name:EDWARDS, TIFFANY NICOLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:NICOLE
Other - Last Name:COCKRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:155 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:SC
Mailing Address - Zip Code:29661-9734
Mailing Address - Country:US
Mailing Address - Phone:864-483-0387
Mailing Address - Fax:
Practice Address - Street 1:155 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:SC
Practice Address - Zip Code:29661-9734
Practice Address - Country:US
Practice Address - Phone:864-483-0387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10033224Z00000X
SC3510224Z00000X
MSTA2852224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant