Healthcare Provider Details

I. General information

NPI: 1881742096
Provider Name (Legal Business Name): TIFFANY CUPP DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 COLLEGE AVENUE
CONWAY AR
72034-9310
US

IV. Provider business mailing address

2505 GLADIOLA
CONWAY AR
72034-8458
US

V. Phone/Fax

Practice location:
  • Phone: 501-329-5459
  • Fax: 501-327-1738
Mailing address:
  • Phone: 501-548-0926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT2852
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: