Provider Demographics
NPI:1194121780
Name:RADER, TIFFANIE
Entity type:Individual
Prefix:MRS
First Name:TIFFANIE
Middle Name:
Last Name:RADER
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 1:10411 T.R. 114
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:OH
Mailing Address - Zip Code:45889
Mailing Address - Country:US
Mailing Address - Phone:419-957-7973
Mailing Address - Fax:
Practice Address - Street 1:10411 T.R. 114
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:OH
Practice Address - Zip Code:45889
Practice Address - Country:US
Practice Address - Phone:419-957-7973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
OH02654224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant