Provider Demographics
NPI:1558009589
Name:FREEMAN, TIFFANI DANIELLE
Entity Type:Individual
Prefix:
First Name:TIFFANI
Middle Name:DANIELLE
Last Name:FREEMAN
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 1:2719 GRAVES DR STE 3
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-4536
Mailing Address - Country:US
Mailing Address - Phone:919-223-6004
Mailing Address - Fax:
Practice Address - Street 1:2719 GRAVES DR STE 3
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-4536
Practice Address - Country:US
Practice Address - Phone:919-223-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC374U00000X
390200000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No374U00000XNursing Service Related ProvidersHome Health Aide
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC882290622Medicaid