Provider Demographics
NPI:1497177505
Name:DAUGHERTY, TIFFANY DAWN
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DAWN
Last Name:DAUGHERTY
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 1:4037 FESTIVAL POINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:MULBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:33860-4514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3020 S FLORIDA AVE STE 207
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4055
Practice Address - Country:US
Practice Address - Phone:501-388-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3145101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health