Healthcare Provider Details

I. General information

NPI: 1063574085
Provider Name (Legal Business Name): TIFFANY A JANISCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 SHELBY RD
LA CROSSE WI
54601-8037
US

IV. Provider business mailing address

PO BOX 45
BANGOR WI
54614-0045
US

V. Phone/Fax

Practice location:
  • Phone: 608-788-5700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1710-027
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: