1790356426 NPI number — MRS. MICHELLE LEIGH SHIPPOS LCSW

Table of content: MEGAN FRYBERGER (NPI 1851924351)

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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