MEDICARE: TIFFANY WILLIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	7501005565	MI
2	225200000X	Physical Therapy Assistant	5502005739	MI

General Provider Information

NPI Number	:	1679439665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY WILLIS

Provider Business Mailing Address
First Line	:	8629 MANNINGTON RD
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-2030
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5536 RESEARCH DR
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-2261
Country	:	US
Telephone Number	:	734-895-1901
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2026
Last Update Date	:	01/02/2026

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Directions to “ TIFFANY WILLIS ” Practice Location

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