Provider Demographics
NPI:1801967427
Name:SCANDRETT, TIFFANY MORRIS (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:MORRIS
Last Name:SCANDRETT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 KIMMERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-2672
Mailing Address - Country:US
Mailing Address - Phone:478-714-3807
Mailing Address - Fax:478-746-1642
Practice Address - Street 1:1385 OGLETHORPE ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1511
Practice Address - Country:US
Practice Address - Phone:478-746-1037
Practice Address - Fax:478-746-1642
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005793235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA305467OtherWELLCARE PROVIDER ID
GA167270852AMedicaid
GA20-0847484OtherTAX IDENTIFICATION NUMBER