MEDICARE: TIFFANY G GATLIN LCDC-I

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	25476	TX

General Provider Information

NPI Number	:	1811479918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY G GATLIN LCDC-I

Provider Business Mailing Address
First Line	:	5401 RAMPART ST APT 529
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77081-1326
Country	:	US
Telephone Number	:	832-372-2584
Fax Number	:	713-228-7903

Provider Business Practice Location Address
First Line	:	5401 RAMPART ST APT 529
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77081-1326
Country	:	US
Telephone Number	:	832-372-2584
Fax Number	:

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

Provider Enumeration Date	:	09/05/2018
Last Update Date	:	09/05/2018

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