Basic Information
| Provider Information | |||||||||
| NPI: | 1437669017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAGG | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | KAYLA | ||||||||
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| Credential: | CDCA, QMHS, CMS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1925 HAYES AVE | ||||||||
| Address2: | |||||||||
| City: | SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448704737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195575177 | ||||||||
| FaxNumber: | 4195575179 | ||||||||
| Practice Location | |||||||||
| Address1: | 76 ASHWOOD DR | ||||||||
| Address2: | |||||||||
| City: | TIFFIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448831908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194489440 | ||||||||
| FaxNumber: | 4194485155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2017 | ||||||||
| LastUpdateDate: | 10/09/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | CDCA.164477 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 101YA0400X | 05 | OH | MEDICAID | 101YM0800X | 05 | OH | MEDICAID |