Provider Demographics
NPI:1316319049
Name:RODRIGUEZ, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:RODRIGUEZ
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 1:1007 LAKEVIEW OAKS DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34715-5782
Mailing Address - Country:US
Mailing Address - Phone:352-444-4179
Mailing Address - Fax:407-602-7858
Practice Address - Street 1:917 N PENNSYLVANIA AVE
Practice Address - Street 2:PREMAPLAY LLC
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2456
Practice Address - Country:US
Practice Address - Phone:407-790-5601
Practice Address - Fax:407-602-7858
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA13822224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013653800Medicaid