Healthcare Provider Details

I. General information

NPI: 1306373758
Provider Name (Legal Business Name): TIFFANY DAWN DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 05/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5480 MCGINNIS VILLAGE PL STE 104
ALPHARETTA GA
30005-1746
US

IV. Provider business mailing address

4255 WADE GREEN RD NW STE 414
KENNESAW GA
30144-1763
US

V. Phone/Fax

Practice location:
  • Phone: 678-213-2194
  • Fax: 678-922-7767
Mailing address:
  • Phone: 678-213-2194
  • Fax: 678-922-7767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW006029
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: