MEDICARE: TIFFANIE GAMBRELL COTTEN MSW,LCSW-A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	1041C0700X	Clinical Social Worker	P013212	NC

General Provider Information

NPI Number	:	1295081560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANIE GAMBRELL COTTEN MSW,LCSW-A

Provider Business Mailing Address
First Line	:	3801 LAKE BOONE TRL STE 100
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27607-2994
Country	:	US
Telephone Number	:	919-600-9665
Fax Number	:	919-256-0781

Provider Business Practice Location Address
First Line	:	3801 LAKE BOONE TRL STE 100
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27607-2994
Country	:	US
Telephone Number	:	919-600-9665
Fax Number	:	919-256-0781

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2012
Last Update Date	:	08/29/2019

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