Healthcare Provider Details

I. General information

NPI: 1598048027
Provider Name (Legal Business Name): TIFFANY KOUADIO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 N PATTERSON ST
VALDOSTA GA
31601-4528
US

IV. Provider business mailing address

332 W 806 N
VALPARAISO IN
46385-7973
US

V. Phone/Fax

Practice location:
  • Phone: 229-469-6932
  • Fax: 229-469-6933
Mailing address:
  • Phone: 219-764-4888
  • Fax: 219-764-7676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number99048622A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: