MEDICARE: TIFFANI J SURRATT LCDCIII

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	LCDC.10102-3	OH

General Provider Information

NPI Number	:	1962759506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANI J SURRATT LCDCIII

Provider Business Mailing Address
First Line	:	2600 VICTORY PKWY
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45206-1711
Country	:	US
Telephone Number	:	513-751-7747
Fax Number	:	513-751-0180

Provider Business Practice Location Address
First Line	:	2222 VINE ST
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45219-1828
Country	:	US
Telephone Number	:	513-751-8600
Fax Number	:	513-751-7747

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

Provider Enumeration Date	:	08/14/2012
Last Update Date	:	08/14/2012

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