Provider Demographics
NPI:1184622383
Name:TIPPETT, TRACI LEANNE
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:LEANNE
Last Name:TIPPETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1678
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37816-1678
Mailing Address - Country:US
Mailing Address - Phone:423-581-5342
Mailing Address - Fax:423-581-8650
Practice Address - Street 1:836 W 1ST NORTH ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-4548
Practice Address - Country:US
Practice Address - Phone:423-581-5342
Practice Address - Fax:423-581-8650
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW36201041C0700X
NMI-074101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3922967Medicaid
TN103I800270Medicare PIN
TN3922968Medicare ID - Type Unspecified