Provider Demographics
NPI:1962584250
Name:WERNER, TIFFANY (OTR)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WERNER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5151 MUNGER SHAW RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MN
Mailing Address - Zip Code:55779-9523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39 N 25TH ST E
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5269
Practice Address - Country:US
Practice Address - Phone:763-689-5385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102008225X00000X
WI3072225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN130G4WEOtherBCBS
MNHP48697OtherHEALTH PARTNERS
MN6405163OtherMEDIDA
WI41810700Medicaid
WI41810700Medicaid