Healthcare Provider Details

I. General information

NPI: 1053989962
Provider Name (Legal Business Name): TIFFANY SIMMS HAIRSTON ADMINISTRATOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3822 SIMMONS CT
GREENSBORO NC
27407-7522
US

IV. Provider business mailing address

3822 SIMMONS CT
GREENSBORO NC
27407-7522
US

V. Phone/Fax

Practice location:
  • Phone: 404-358-0717
  • Fax:
Mailing address:
  • Phone: 404-358-0717
  • Fax: 678-736-8096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberMHL-041-1354
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: