MEDICARE: TIFFANY M AVERETTE-SMITH LCSW, MAC

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	1041C0700X	Clinical Social Worker	CSW004823	GA

General Provider Information

NPI Number	:	1619302536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY M AVERETTE-SMITH LCSW, MAC

Provider Business Mailing Address
First Line	:	PO BOX 418
Second Line	:
City	:	AVONDALE ESTATES
State	:	GA
Zip	:	30002-0418
Country	:	US
Telephone Number	:	330-313-5773
Fax Number	:

Provider Business Practice Location Address
First Line	:	1915 ROCK CUT PL
Second Line	:
City	:	CONLEY
State	:	GA
Zip	:	30288-2104
Country	:	US
Telephone Number	:	330-313-5773
Fax Number	:

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

Provider Enumeration Date	:	09/10/2013
Last Update Date	:	07/08/2019

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