Healthcare Provider Details

I. General information

NPI: 1194706887
Provider Name (Legal Business Name): CHARLES EDWIN TIFT LMSW, NCAC II, CCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 GARDEN CIR
HINESVILLE GA
31313-4421
US

IV. Provider business mailing address

36 COATES RD
HINESVILLE GA
31313-1013
US

V. Phone/Fax

Practice location:
  • Phone: 912-977-4663
  • Fax: 912-369-6530
Mailing address:
  • Phone: 912-369-5973
  • Fax: 912-369-6530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number012789
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMSW002656
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: