Provider Demographics
NPI:1588935654
Name:GARDNER, TIFFANY (OT)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6950 GREENBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-7388
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6950 GREENBRIAR DR
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-7388
Practice Address - Country:US
Practice Address - Phone:918-519-2442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-22
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOT571225XL0004X, 225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistLow Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200456840AMedicaid