Provider Demographics
NPI:1659781805
Name:TIPTON, MANDI (LAC)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:
Last Name:TIPTON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1237 W DIVIDE AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1220
Mailing Address - Country:US
Mailing Address - Phone:701-328-8833
Mailing Address - Fax:
Practice Address - Street 1:1237 W DIVIDE AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1220
Practice Address - Country:US
Practice Address - Phone:701-328-8833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1726101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)