Provider Demographics
NPI:1003629056
Name:TIPPITT, BLAKE
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:TIPPITT
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3921 PINTAIL DR STE B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-6738
Mailing Address - Country:US
Mailing Address - Phone:502-297-0133
Mailing Address - Fax:
Practice Address - Street 1:2535 MILLIKIN PKWY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-2156
Practice Address - Country:US
Practice Address - Phone:217-685-2549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician