Basic Information
| Provider Information | |||||||||
| NPI: | 1710227178 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DEAN | ||||||||
| FirstName: | TIFFANY | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 NE LOOP 820 BUSINESS TOWER 1 | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HURST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177898787 | ||||||||
| FaxNumber: | 8177896849 | ||||||||
| Practice Location | |||||||||
| Address1: | 5225 S LOOP 289 | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794241363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067804180 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2013 | ||||||||
| LastUpdateDate: | 07/22/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 114574 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 331042299 | 05 | TX | MEDICAID |