Provider Demographics
NPI:1861079550
Name:POWELL, TIFFANY L (MT)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:L
Last Name:POWELL
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 PACKER DR # 103
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404-1151
Mailing Address - Country:US
Mailing Address - Phone:530-414-8715
Mailing Address - Fax:
Practice Address - Street 1:3245 PACKER DR # 103
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-1151
Practice Address - Country:US
Practice Address - Phone:530-414-8715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14889-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist