Provider Demographics
NPI:1710146782
Name:TIPTON, KELLY RENEE (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RENEE
Last Name:TIPTON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:655 CRAIG RD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7132
Mailing Address - Country:US
Mailing Address - Phone:314-374-4703
Mailing Address - Fax:314-457-1653
Practice Address - Street 1:655 CRAIG RD
Practice Address - Street 2:SUITE 320
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7132
Practice Address - Country:US
Practice Address - Phone:314-374-4703
Practice Address - Fax:314-457-1653
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006035741101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional