Healthcare Provider Details

I. General information

NPI: 1528759768
Provider Name (Legal Business Name): TIFFANY COLE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 BROAD AVE
GULFPORT MS
39501-3603
US

IV. Provider business mailing address

PO BOX 18679
HATTIESBURG MS
39404-8679
US

V. Phone/Fax

Practice location:
  • Phone: 228-213-5888
  • Fax: 222-857-5343
Mailing address:
  • Phone: 601-705-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM9942
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: