Provider Demographics
NPI:1093445249
Name:TIPPY, SAMANTHA JEAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:JEAN
Last Name:TIPPY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4814 WESTGARDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2639
Mailing Address - Country:US
Mailing Address - Phone:815-210-5045
Mailing Address - Fax:
Practice Address - Street 1:4814 WESTGARDEN BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2639
Practice Address - Country:US
Practice Address - Phone:815-210-5045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010775103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical