Provider Demographics
NPI:1417576992
Name:TRAUTNER, TIFFANY MICHELE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MICHELE
Last Name:TRAUTNER
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 1:1135 SENOIA RD
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-1625
Mailing Address - Country:US
Mailing Address - Phone:770-626-3044
Mailing Address - Fax:
Practice Address - Street 1:1135 SENOIA RD
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-1625
Practice Address - Country:US
Practice Address - Phone:770-626-3044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-16-25686106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003218736AMedicaid