Provider Demographics
NPI:1386364958
Name:TINO, TIFFANY RAE (COTA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:RAE
Last Name:TINO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 SW 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-8523
Mailing Address - Country:US
Mailing Address - Phone:518-421-4619
Mailing Address - Fax:
Practice Address - Street 1:1700 N DIXIE HWY STE 116
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-1807
Practice Address - Country:US
Practice Address - Phone:844-397-5011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225000000X, 225XG0600X, 225XM0800X, 225XP0200X
FL359826224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics