Healthcare Provider Details

I. General information

NPI: 1639747793
Provider Name (Legal Business Name): TIFFANY J TREESE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

IV. Provider business mailing address

158 SWAN RD
HOLLIDAYSBURG PA
16648-5202
US

V. Phone/Fax

Practice location:
  • Phone: 570-769-5349
  • Fax:
Mailing address:
  • Phone: 814-937-2454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOP001503L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: