Healthcare Provider Details

I. General information

NPI: 1154948222
Provider Name (Legal Business Name): TIFFANY FLOYD MS, CTRS, CDP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 07/06/2020
Certification Date: 07/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E WOODROW WILSON AVE
JACKSON MS
39216-5116
US

IV. Provider business mailing address

PO BOX 612
PINE GROVE LA
70453-0612
US

V. Phone/Fax

Practice location:
  • Phone: 601-882-2877
  • Fax:
Mailing address:
  • Phone: 225-341-0857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number41864
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: