1790356426 NPI number — MRS. MICHELLE LEIGH SHIPPOS LCSW

Table of content: MRS. MICHELLE LEIGH SHIPPOS LCSW (NPI 1790356426)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790356426 NPI number — MRS. MICHELLE LEIGH SHIPPOS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIPPOS
Provider First Name:
MICHELLE
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCOTT
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
LEIGH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790356426
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 N MEADOW ST UNIT 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ITHACA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14850-4027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-862-6252
Provider Business Mailing Address Fax Number:
844-333-0375

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 N MEADOW ST UNIT 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ITHACA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14850-4027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-862-6252
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/04/2021

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:  088525 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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