Provider Demographics
NPI:1275019531
Name:PIPPINS, MICHELLE GRUBBS
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GRUBBS
Last Name:PIPPINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ASHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-2643
Mailing Address - Country:US
Mailing Address - Phone:937-673-8951
Mailing Address - Fax:937-221-8003
Practice Address - Street 1:117 ASHWOOD AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-2643
Practice Address - Country:US
Practice Address - Phone:937-673-8951
Practice Address - Fax:937-673-8951
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 171M00000X
OHRT292151172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriver
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1326651084Medicaid