Provider Demographics
NPI:1538652425
Name:BAGGETT, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:BAGGETT
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 1:1650 BARNES MILL RD APT 223
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-7553
Mailing Address - Country:US
Mailing Address - Phone:678-799-4191
Mailing Address - Fax:
Practice Address - Street 1:1650 BARNES MILL RD APT 223
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-7553
Practice Address - Country:US
Practice Address - Phone:678-799-4191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251K00000X
322D00000X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251K00000XAgenciesPublic Health or Welfare
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children