Provider Demographics
NPI:1164052247
Name:JOHNSON, TIFFANY DEWONNA (CAC- IN PROCESS)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DEWONNA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CAC- IN PROCESS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 LAKE FRANCES DR
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29170-3871
Mailing Address - Country:US
Mailing Address - Phone:803-429-1259
Mailing Address - Fax:
Practice Address - Street 1:204 N RAMAGE ST
Practice Address - Street 2:
Practice Address - City:SALUDA
Practice Address - State:SC
Practice Address - Zip Code:29138-1359
Practice Address - Country:US
Practice Address - Phone:864-445-2968
Practice Address - Fax:864-445-9592
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIN-PROCESS101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)