Provider Demographics
NPI:1881174662
Name:MCBRIDE, TIFFANY ANTIONETTE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANTIONETTE
Last Name:MCBRIDE
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 1:719 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SC
Mailing Address - Zip Code:29571-2517
Mailing Address - Country:US
Mailing Address - Phone:843-423-1811
Mailing Address - Fax:843-423-8328
Practice Address - Street 1:2320 SC-41 ALT
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SC
Practice Address - Zip Code:29571
Practice Address - Country:US
Practice Address - Phone:843-423-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor