MEDICARE: TIFFANY D PICKETT DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT29335	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y0P8J	OTHER	FL	FLORIDA BLUE

General Provider Information

NPI Number	:	1053716175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY D PICKETT DPT

Provider Business Mailing Address
First Line	:	80 TECHNACENTER DR
Second Line	:	SUITE 300
City	:	MONTGOMERY
State	:	AL
Zip	:	36117-6028
Country	:	US
Telephone Number	:	334-625-5795
Fax Number	:	334-396-4905

Provider Business Practice Location Address
First Line	:	8199 NAVARRE PKWY
Second Line	:	UNIT 12A
City	:	NAVARRE
State	:	FL
Zip	:	32566-6941
Country	:	US
Telephone Number	:	850-939-1233
Fax Number	:	850-939-5097

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2014
Last Update Date	:	03/15/2016

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Directions to “ TIFFANY D PICKETT DPT” Practice Location

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