Provider Demographics
NPI:1508129750
Name:NESBIT, TIFFANY KEYA
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:KEYA
Last Name:NESBIT
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 1:164 WACCAMAW MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8903
Mailing Address - Country:US
Mailing Address - Phone:843-347-5060
Mailing Address - Fax:
Practice Address - Street 1:164 WACCAMAW MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8903
Practice Address - Country:US
Practice Address - Phone:843-347-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health