Provider Demographics
NPI:1972108538
Name:GOTH, TIFFANY PAIGE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:PAIGE
Last Name:GOTH
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 1:12276 SAN JOSE BLVD STE 508
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8618
Mailing Address - Country:US
Mailing Address - Phone:904-886-3228
Mailing Address - Fax:
Practice Address - Street 1:12276 SAN JOSE BLVD STE 508
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8618
Practice Address - Country:US
Practice Address - Phone:904-886-3228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21127225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist