Provider Demographics
NPI:1568494565
Name:SHIPLEY, M SUSAN (LCSW, ACSW, MSW)
Entity Type:Individual
Prefix:MS
First Name:M
Middle Name:SUSAN
Last Name:SHIPLEY
Suffix:
Gender:F
Credentials:LCSW, ACSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1814
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37621-1814
Mailing Address - Country:US
Mailing Address - Phone:423-968-5050
Mailing Address - Fax:
Practice Address - Street 1:523 HOLSTON AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-2131
Practice Address - Country:US
Practice Address - Phone:423-968-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3011513OtherBCBS NONPAR
TN3695533Medicare ID - Type Unspecified