1609850221 NPI number — MR. CORY MELVIN SHIPP LCSW

Table of content: MR. CORY MELVIN SHIPP LCSW (NPI 1609850221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609850221 NPI number — MR. CORY MELVIN SHIPP LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIPP
Provider First Name:
CORY
Provider Middle Name:
MELVIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609850221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1141 E 3900 S
Provider Second Line Business Mailing Address:
SUITE A-170
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84124-1215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-284-4990
Provider Business Mailing Address Fax Number:
801-284-4991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1141 EAST 3900 SOUTH
Provider Second Line Business Practice Location Address:
SUITE A-170
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-284-4990
Provider Business Practice Location Address Fax Number:
801-284-4991
Provider Enumeration Date:
12/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  4933215-3501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 493321535000001 . This is a "BLUE CROSS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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