Healthcare Provider Details

I. General information

NPI: 1881174662
Provider Name (Legal Business Name): TIFFANY ANTIONETTE MCBRIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 SC-41 ALT
MARION SC
29571
US

IV. Provider business mailing address

719 N MAIN ST
MARION SC
29571-2517
US

V. Phone/Fax

Practice location:
  • Phone: 843-423-8345
  • Fax:
Mailing address:
  • Phone: 843-423-1811
  • Fax: 843-423-8328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: