Provider Demographics
NPI:1124399589
Name:DERRICK, TIFFANY R (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:R
Last Name:DERRICK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 DAWSONVILLE HWY STE 2201
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2632
Mailing Address - Country:US
Mailing Address - Phone:678-701-8477
Mailing Address - Fax:229-516-1395
Practice Address - Street 1:629 DAWSONVILLE HWY STE 2201
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2632
Practice Address - Country:US
Practice Address - Phone:678-701-8477
Practice Address - Fax:229-516-1395
Is Sole Proprietor?:No
Enumeration Date:2012-01-17
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL180.009330101YP2500X
GALPC008265101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health