Basic Information
| Provider Information | |||||||||
| NPI: | 1780182931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TURNER | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCDCIII.162058 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 323 MARION PIKE STE 3 | ||||||||
| Address2: | |||||||||
| City: | COAL GROVE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456382958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406466640 | ||||||||
| FaxNumber: | 8664757263 | ||||||||
| Practice Location | |||||||||
| Address1: | 323 MARION PIKE STE 3 | ||||||||
| Address2: | |||||||||
| City: | COAL GROVE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456382958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406466640 | ||||||||
| FaxNumber: | 8664757263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2018 | ||||||||
| LastUpdateDate: | 04/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.165844 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | LCDCIII.162058 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0259277 | 05 | OH | MEDICAID |