Provider Demographics
NPI:1396218731
Name:BRUCE, TIFFANY NACOLE (LCSW)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NACOLE
Last Name:BRUCE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 VAN AALST BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MOORE
Mailing Address - State:GA
Mailing Address - Zip Code:31905-2102
Mailing Address - Country:US
Mailing Address - Phone:762-408-4076
Mailing Address - Fax:
Practice Address - Street 1:6600 VAN AALST BLVD
Practice Address - Street 2:
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905-2102
Practice Address - Country:US
Practice Address - Phone:301-875-7137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD237511041C0700X
GACSW0080531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical