Provider Demographics
NPI:1780016030
Name:JUDKINS, TIFFANY M (LCSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:M
Last Name:JUDKINS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 WINCHESTER TRAIL SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3815
Mailing Address - Country:US
Mailing Address - Phone:404-594-2079
Mailing Address - Fax:
Practice Address - Street 1:1117 WINCHESTER TRAIL SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339
Practice Address - Country:US
Practice Address - Phone:404-594-2079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0058351041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000606317BMedicaid
GAGRP2010Medicare PIN