Provider Demographics
NPI:1700280195
Name:POLLOCK, TIFFANY (OTR/L)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:POLLOCK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11536 W PRISTINEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5784
Mailing Address - Country:US
Mailing Address - Phone:208-654-6161
Mailing Address - Fax:208-473-7320
Practice Address - Street 1:316 E 1ST ST
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644
Practice Address - Country:US
Practice Address - Phone:208-654-6161
Practice Address - Fax:208-473-7320
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-547225X00000X, 225XF0002X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & Swallowing