Provider Demographics
NPI:1467612168
Name:TIPTON, MARICA SHAVA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARICA
Middle Name:SHAVA
Last Name:TIPTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARICA
Other - Middle Name:SHAVA
Other - Last Name:WILLSON-TIPTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2125 DERRIN LN
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2151
Mailing Address - Country:US
Mailing Address - Phone:414-297-7745
Mailing Address - Fax:262-641-9768
Practice Address - Street 1:2125 DERRIN LN
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2151
Practice Address - Country:US
Practice Address - Phone:414-297-7745
Practice Address - Fax:262-641-9768
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4775-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43715200Medicaid