Provider Demographics
NPI:1750540878
Name:ENGSTROM, TIFFANY NICOLE (OT)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:ENGSTROM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 DUTCHMANS LN
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4722
Mailing Address - Country:US
Mailing Address - Phone:502-899-9927
Mailing Address - Fax:502-899-5810
Practice Address - Street 1:3901 DUTCHMANS LN
Practice Address - Street 2:SUITE 104
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4722
Practice Address - Country:US
Practice Address - Phone:502-899-9927
Practice Address - Fax:502-899-5810
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3584225X00000X
KYR4158225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist