Basic Information
| Provider Information | |||||||||
| NPI: | 1811205321 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEISER | ||||||||
| FirstName: | TIFFANY | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2211 I-35 SOUTH | ||||||||
| Address2: | STE 300 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123940652 | ||||||||
| FaxNumber: | 5123941436 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 I-35 SOUTH | ||||||||
| Address2: | STE 300 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123940652 | ||||||||
| FaxNumber: | 5123941436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2010 | ||||||||
| LastUpdateDate: | 09/17/2010 | ||||||||
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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 | 225100000X | 1200001 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 149984001 | 05 | TX | MEDICAID | 207164901 | 05 | TX | MEDICAID |