Provider Demographics
NPI:1154041200
Name:HODGE, TIFFANY MICHELLE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MICHELLE
Last Name:HODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6708
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30916-6708
Mailing Address - Country:US
Mailing Address - Phone:762-221-1734
Mailing Address - Fax:
Practice Address - Street 1:2893 PEPPERDINE DR
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815-6160
Practice Address - Country:US
Practice Address - Phone:762-221-1734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13378104100000X
GAMSW007125104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker