Basic Information
| Provider Information | |||||||||
| NPI: | 1487270377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLTON | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | VE'SHARNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4185 MAY APPLE LN | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303498223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782351036 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1670 CLAIRMONT RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300334004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043216111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2020 | ||||||||
| LastUpdateDate: | 06/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 007690 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.