Provider Demographics
NPI:1962759506
Name:SURRATT, TIFFANI J (LCDCIII)
Entity type:Individual
Prefix:
First Name:TIFFANI
Middle Name:J
Last Name:SURRATT
Suffix:
Gender:F
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 VICTORY PKWY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1711
Mailing Address - Country:US
Mailing Address - Phone:513-751-7747
Mailing Address - Fax:513-751-0180
Practice Address - Street 1:2222 VINE ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-1828
Practice Address - Country:US
Practice Address - Phone:513-751-8600
Practice Address - Fax:513-751-7747
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDC.10102-3101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)