MEDICARE: TIFFANY BRIDGES LCSW-A, LCAS-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	1041C0700X	Clinical Social Worker	PO12239	NC
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCAS-24476	NC

General Provider Information

NPI Number	:	1427516301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY BRIDGES LCSW-A, LCAS-A

Provider Business Mailing Address
First Line	:	3717 LATROBE DR STE 750
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-4826
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3717 LATROBE DR STE 750
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-4826
Country	:	US
Telephone Number	:	980-288-5486
Fax Number	:

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

Provider Enumeration Date	:	03/09/2019
Last Update Date	:	02/09/2020

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