Basic Information
| Provider Information | |||||||||
| NPI: | 1568740348 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOLTER | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | POULIN | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MHP, CDP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 918 | ||||||||
| Address2: | |||||||||
| City: | BENNETTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435444060 | ||||||||
| FaxNumber: | 2069012010 | ||||||||
| Practice Location | |||||||||
| Address1: | 1035 CHERAW HWY | ||||||||
| Address2: | |||||||||
| City: | BENNETTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435444060 | ||||||||
| FaxNumber: | 2063022210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2011 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP00004297 | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | CG60204032 | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 405127 | 05 | SC | MEDICAID |