Provider Demographics
NPI:1053539080
Name:COOLEY, TIFFANY (LAC, CFMP)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:COOLEY
Suffix:
Gender:F
Credentials:LAC, CFMP
Other - Prefix:
Other - First Name:NALU
Other - Middle Name:
Other - Last Name:COOLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC, CFMP
Mailing Address - Street 1:2405 MORENA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4139
Mailing Address - Country:US
Mailing Address - Phone:619-957-3303
Mailing Address - Fax:
Practice Address - Street 1:2405 MORENA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4139
Practice Address - Country:US
Practice Address - Phone:619-957-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023682225700000X
CA16997171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA523981-06OtherNATIONAL CERTIFICATION
WA200417OtherAMTA MEMBER
WAMA00023682OtherMASSAGE LICENSE
CA16997OtherCALIFORNIA ACUPUNCTURE LICENSE
WA217345OtherLABOR AND INDUSTRIES
WA602691997OtherUBI NUMBER