Provider Demographics
NPI:1366578650
Name:TIPTON, CONNIE LYNN
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:LYNN
Last Name:TIPTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NA
Other - Middle Name:NA
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3322
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95353-3322
Mailing Address - Country:US
Mailing Address - Phone:209-525-7412
Mailing Address - Fax:209-525-7457
Practice Address - Street 1:800 SCENIC DR BLDG F
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6131
Practice Address - Country:US
Practice Address - Phone:209-525-7412
Practice Address - Fax:209-525-7457
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health