Provider Demographics
NPI:1245655893
Name:GILMORE RANDELL, TIFFANY (PSYD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:GILMORE RANDELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 HWY 85 N
Mailing Address - Street 2:STE 310-222
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214
Mailing Address - Country:US
Mailing Address - Phone:404-585-5439
Mailing Address - Fax:678-802-0398
Practice Address - Street 1:101 DEVANT STREET,
Practice Address - Street 2:OFFICE 401
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:404-585-5439
Practice Address - Fax:678-802-0398
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY00365103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA430767825AMedicaid