Provider Demographics
NPI:1619302536
Name:AVERETTE-SMITH, TIFFANY M (LCSW, MAC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:M
Last Name:AVERETTE-SMITH
Suffix:
Gender:F
Credentials:LCSW, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-0418
Mailing Address - Country:US
Mailing Address - Phone:330-313-5773
Mailing Address - Fax:
Practice Address - Street 1:1915 ROCK CUT PL
Practice Address - Street 2:
Practice Address - City:CONLEY
Practice Address - State:GA
Practice Address - Zip Code:30288-2104
Practice Address - Country:US
Practice Address - Phone:330-313-5773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0048231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical