1386332575 NPI number — MADELINE KAREN TIPPETT MA, ATR, LPC

Table of content: MADELINE KAREN TIPPETT MA, ATR, LPC (NPI 1386332575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386332575 NPI number — MADELINE KAREN TIPPETT MA, ATR, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIPPETT
Provider First Name:
MADELINE
Provider Middle Name:
KAREN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, ATR, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOLFE
Provider Other First Name:
MADELINE
Provider Other Middle Name:
KAREN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, ATR, LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1386332575
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4211 N PROSPECT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61616-7754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-691-5502
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4211 N PROSPECT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61616-7754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-691-5502
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/26/2023

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: 101YP2500X , with the licence number:  178.016362 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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