Healthcare Provider Details

I. General information

NPI: 1588968671
Provider Name (Legal Business Name): TIFFANIE WARZECHA OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 W EAU GALLIE BLVD
MELBOURNE FL
32934-7213
US

IV. Provider business mailing address

469 BIMINI LN
INDIAN HARBOUR BEACH FL
32937-4410
US

V. Phone/Fax

Practice location:
  • Phone: 321-255-6627
  • Fax:
Mailing address:
  • Phone: 812-589-6005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT 14442
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT23699
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: