=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548941578
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TONI MILES TOMBERLIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2023
-----------------------------------------------------
Last Update Date | 07/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 597 MAX DEEN DR
-----------------------------------------------------
City | BAXLEY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31513-8235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-278-0494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 477
-----------------------------------------------------
City | BAXLEY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31515-0477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-278-0494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------