Provider Demographics
NPI:1578317681
Name:KIPKE, TABITHA
Entity Type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:
Last Name:KIPKE
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 1:2650 COTTAGE LN
Mailing Address - Street 2:
Mailing Address - City:HARSENS ISLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48028-9716
Mailing Address - Country:US
Mailing Address - Phone:586-206-0670
Mailing Address - Fax:
Practice Address - Street 1:400 STODDARD RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MI
Practice Address - Zip Code:48062-2505
Practice Address - Country:US
Practice Address - Phone:810-392-2167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704277955101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)