Provider Demographics
NPI:1073671806
Name:TIPTON, EDWARD N (LP)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:N
Last Name:TIPTON
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1291 BLUFF CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-9515
Mailing Address - Country:US
Mailing Address - Phone:952-496-9756
Mailing Address - Fax:
Practice Address - Street 1:1291 BLUFF CREEK DR
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-9515
Practice Address - Country:US
Practice Address - Phone:952-496-9757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2010-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4941103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1073671806OtherMINNESOTA HEALTH CARE PROGRAMS ('MEDICAL ASSISTANCE')