MEDICARE: TIFFANY NICOLE ENGSTROM OT

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	225X00000X	Occupational Therapist	3584	TN
2	225X00000X	Occupational Therapist	R4158	KY

General Provider Information

NPI Number	:	1750540878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY NICOLE ENGSTROM OT

Provider Business Mailing Address
First Line	:	3901 DUTCHMANS LN
Second Line	:	SUITE 104
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-4722
Country	:	US
Telephone Number	:	502-899-9927
Fax Number	:	502-899-5810

Provider Business Practice Location Address
First Line	:	3901 DUTCHMANS LN
Second Line	:	SUITE 104
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-4722
Country	:	US
Telephone Number	:	502-899-9927
Fax Number	:	502-899-5810

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

Provider Enumeration Date	:	06/04/2008
Last Update Date	:	04/27/2009

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