Basic Information
| Provider Information | |||||||||
| NPI: | 1760107718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUMAYOG | ||||||||
| FirstName: | TIFFANY CLAIRE | ||||||||
| MiddleName: | VILLARTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 E JOPPA RD | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212865404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108289494 | ||||||||
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| Practice Location | |||||||||
| Address1: | 509 E JOPPA RD | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212865404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108289494 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2022 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XG0600X | A02677 | MD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Gerontology | 224Z00000X | A02677 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1559696656 | 01 | MD | MANAGED-CARE | OTHER | 1559696656 | 05 | MD | MEDICAID |