Provider Demographics
NPI:1225802101
Name:TEA, TIFFANY NICOLE (PT, DPT)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:TEA
Suffix:
Gender:F
Credentials:PT, DPT
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 715868
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19171-5868
Mailing Address - Country:US
Mailing Address - Phone:804-915-1910
Mailing Address - Fax:804-968-1803
Practice Address - Street 1:1850 TOWN CENTER PKWY STE 403
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3300
Practice Address - Country:US
Practice Address - Phone:703-810-5203
Practice Address - Fax:703-810-5408
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305216185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist