Healthcare Provider Details

I. General information

NPI: 1669479838
Provider Name (Legal Business Name): TIFFANY BIRT OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2005
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LINDSEY LN B
KINGSLAND GA
31548-6850
US

IV. Provider business mailing address

100 LINDSEY LN B
KINGSLAND GA
31548-6850
US

V. Phone/Fax

Practice location:
  • Phone: 912-510-6104
  • Fax: 912-882-6134
Mailing address:
  • Phone: 912-510-6104
  • Fax: 912-882-6134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT003805
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: