Provider Demographics
NPI:1194076463
Name:MERRIMAN, TIFFANY J (PTA)
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:J
Last Name:MERRIMAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6142
Mailing Address - Country:US
Mailing Address - Phone:715-832-1618
Mailing Address - Fax:
Practice Address - Street 1:2120 HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6142
Practice Address - Country:US
Practice Address - Phone:715-832-1618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1542-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1194076463Medicaid