Provider Demographics
NPI:1447692736
Name:CROCKETT, TIFFANY L (LMT)
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:L
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-7001
Mailing Address - Country:US
Mailing Address - Phone:520-257-0530
Mailing Address - Fax:
Practice Address - Street 1:2030 E BROADWAY BLVD STE 15
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-5907
Practice Address - Country:US
Practice Address - Phone:520-257-0530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-27
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17763225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist