Provider Demographics
NPI:1407536436
Name:RJ TIPPETT, LLC
Entity Type:Organization
Organization Name:RJ TIPPETT, LLC
Other - Org Name:ROOTED THERAPEUTIC HEALING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:NICHOLE
Authorized Official - Last Name:THIELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:419-481-0806
Mailing Address - Street 1:25940 W RIVER RD
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-9786
Mailing Address - Country:US
Mailing Address - Phone:419-481-0806
Mailing Address - Fax:
Practice Address - Street 1:4334 W CENTRAL AVE STE 202
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-1679
Practice Address - Country:US
Practice Address - Phone:419-766-9604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-24
Last Update Date:2024-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0022954Medicaid
OH0221379Medicaid