Provider Demographics
NPI:1306373758
Name:DAVIS, TIFFANY DAWN
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DAWN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 WADE GREEN RD NW STE 414
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1763
Mailing Address - Country:US
Mailing Address - Phone:678-213-2194
Mailing Address - Fax:678-922-7767
Practice Address - Street 1:5480 MCGINNIS VILLAGE PL STE 104
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-1746
Practice Address - Country:US
Practice Address - Phone:678-213-2194
Practice Address - Fax:678-922-7767
Is Sole Proprietor?:No
Enumeration Date:2017-05-16
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0060291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical