Provider Demographics
NPI:1164066114
Name:TIPPEN, SHELSEA MAGAN (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:SHELSEA
Middle Name:MAGAN
Last Name:TIPPEN
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12870 WARREN LN
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-8317
Mailing Address - Country:US
Mailing Address - Phone:573-625-1724
Mailing Address - Fax:
Practice Address - Street 1:338 BROADWAY ST STE 301
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-7331
Practice Address - Country:US
Practice Address - Phone:573-225-6678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-02
Last Update Date:2019-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-19-37807103K00000X
MO2017028783103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst