Provider Demographics
NPI:1366774283
Name:ACKERSON, TIFFANIE RENAE (MT-BC, NMT)
Entity type:Individual
Prefix:
First Name:TIFFANIE
Middle Name:RENAE
Last Name:ACKERSON
Suffix:
Gender:F
Credentials:MT-BC, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 ALYSE ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:TX
Mailing Address - Zip Code:77536-2806
Mailing Address - Country:US
Mailing Address - Phone:281-904-8389
Mailing Address - Fax:
Practice Address - Street 1:805 ALYSE ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:TX
Practice Address - Zip Code:77536-2806
Practice Address - Country:US
Practice Address - Phone:281-904-8389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL07425225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist