Provider Demographics
NPI:1902836554
Name:TIPTON, GARY LEE (EDD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:TIPTON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14015 LOCHSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-1830
Mailing Address - Country:US
Mailing Address - Phone:281-589-7742
Mailing Address - Fax:
Practice Address - Street 1:25810 OAK RIDGE DR
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-2016
Practice Address - Country:US
Practice Address - Phone:281-364-0067
Practice Address - Fax:281-364-0712
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-3388103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86745AOtherBCBS
TX86745AOtherBCBS