Provider Demographics
NPI:1851952931
Name:MARCELO, TIFFANY
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:
Last Name:MARCELO
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 1:6350 REIVES RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-9210
Mailing Address - Country:US
Mailing Address - Phone:770-241-8461
Mailing Address - Fax:
Practice Address - Street 1:6350 REIVES RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-9210
Practice Address - Country:US
Practice Address - Phone:770-241-8461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASC19013171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASC19013OtherSERVICE COORDINATOR CERTIFICATE