Provider Demographics
NPI:1063150308
Name:STANTON, TIFFANY SUZANNE (OTR)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:SUZANNE
Last Name:STANTON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4083 AMBERLEIGH PKWY
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-3134
Mailing Address - Country:US
Mailing Address - Phone:314-780-0369
Mailing Address - Fax:
Practice Address - Street 1:1150 HANLEY INDUSTRIAL CT
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-1910
Practice Address - Country:US
Practice Address - Phone:314-968-9313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004957225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist