Basic Information
| Provider Information | |||||||||
| NPI: | 1477992766 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRIDDY | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 404 PUBLIC SQ | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427281458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706340841 | ||||||||
| FaxNumber: | 5136364283 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 WINSTON WAY | ||||||||
| Address2: | |||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427184990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707890034 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2013 | ||||||||
| LastUpdateDate: | 07/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | E.1600041 | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | LPCPCC00218310 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 610661458 | 01 | KY | TAX ID | OTHER |