Provider Demographics
NPI:1093766545
Name:CARPENTER, TIFFANY JACKSON (OTR)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:JACKSON
Last Name:CARPENTER
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 1:6250 GREEN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:CHRISTOVAL
Mailing Address - State:TX
Mailing Address - Zip Code:76935-3381
Mailing Address - Country:US
Mailing Address - Phone:325-896-7554
Mailing Address - Fax:325-944-4556
Practice Address - Street 1:3126 APPALOOSA CIR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901
Practice Address - Country:US
Practice Address - Phone:325-944-4399
Practice Address - Fax:325-944-4556
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105626225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T0538OtherBLUE CROSS BLUE SHIELD
TX8T0538OtherBLUE CROSS BLUE SHIELD
TX8T0538Medicare ID - Type Unspecified