Provider Demographics
NPI:1457472383
Name:DEVINE, TIPPHANY DIANE (LPC)
Entity Type:Individual
Prefix:
First Name:TIPPHANY
Middle Name:DIANE
Last Name:DEVINE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 HASKELL STREET
Mailing Address - Street 2:STE. 103
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107
Mailing Address - Country:US
Mailing Address - Phone:817-569-5085
Mailing Address - Fax:817-569-5088
Practice Address - Street 1:1051 HASKELL STREET
Practice Address - Street 2:STE. 103
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-569-5085
Practice Address - Fax:817-569-5088
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18635101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-1285603OtherEIN