Provider Demographics
NPI:1952790727
Name:WILLIAMS, TIFFANIE WIGSTROM (LPC)
Entity Type:Individual
Prefix:
First Name:TIFFANIE
Middle Name:WIGSTROM
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12195 HWY 92, STE. 114
Mailing Address - Street 2:#341
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188
Mailing Address - Country:US
Mailing Address - Phone:470-531-8400
Mailing Address - Fax:470-531-8484
Practice Address - Street 1:251 RIVER PARK NORTH DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-7835
Practice Address - Country:US
Practice Address - Phone:470-531-8400
Practice Address - Fax:470-531-8484
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010114101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003218462AMedicaid