Provider Demographics
NPI:1740460302
Name:BOURGET, TIFFANY NICOLE (OTR/L)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:BOURGET
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 1:306 CONCORD CT
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-1404
Mailing Address - Country:US
Mailing Address - Phone:859-576-2973
Mailing Address - Fax:
Practice Address - Street 1:306 CONCORD CT
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-1404
Practice Address - Country:US
Practice Address - Phone:859-576-2973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-11
Last Update Date:2007-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R3242171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor