Provider Demographics
NPI:1356413652
Name:TIPTON, DONALD SHANE
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:SHANE
Last Name:TIPTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3554 W CHRISTINE CIR APT 3
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-4640
Mailing Address - Country:US
Mailing Address - Phone:714-995-2705
Mailing Address - Fax:
Practice Address - Street 1:211 W COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1810
Practice Address - Country:US
Practice Address - Phone:714-447-7000
Practice Address - Fax:714-447-7003
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty