Provider Demographics
NPI:1609850221
Name:SHIPP, CORY MELVIN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:MELVIN
Last Name:SHIPP
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 E 3900 S
Mailing Address - Street 2:SUITE A-170
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1215
Mailing Address - Country:US
Mailing Address - Phone:801-284-4990
Mailing Address - Fax:801-284-4991
Practice Address - Street 1:1141 EAST 3900 SOUTH
Practice Address - Street 2:SUITE A-170
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-284-4990
Practice Address - Fax:801-284-4991
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4933215-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT493321535000001OtherBLUE CROSS