Provider Demographics
NPI:1063574085
Name:JANISCH, TIFFANY A
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:A
Last Name:JANISCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:WI
Mailing Address - Zip Code:54614-0045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 SHELBY RD
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-8037
Practice Address - Country:US
Practice Address - Phone:608-788-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1710-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant