MEDICARE: MRS. TIFFANY R DERRICK LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor	180.009330	IL
3	101YP2500X	Professional Counselor	LPC008265	GA

General Provider Information

NPI Number	:	1124399589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TIFFANY R DERRICK LCPC

Provider Business Mailing Address
First Line	:	629 DAWSONVILLE HWY STE 2201
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-2632
Country	:	US
Telephone Number	:	678-701-8477
Fax Number	:	229-516-1395

Provider Business Practice Location Address
First Line	:	629 DAWSONVILLE HWY STE 2201
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-2632
Country	:	US
Telephone Number	:	678-701-8477
Fax Number	:	229-516-1395

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2012
Last Update Date	:	01/25/2024

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