Provider Demographics
NPI:1720503592
Name:TIPPIE, MONIKA
Entity Type:Individual
Prefix:
First Name:MONIKA
Middle Name:
Last Name:TIPPIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:
Other - Last Name:TIPPIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 NW 23RD PLACE STE 6
Mailing Address - Street 2:#385
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-847-9720
Mailing Address - Fax:
Practice Address - Street 1:25 NW 23RD PLACE STE 6
Practice Address - Street 2:#385
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:503-847-9720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101599106H00000X
CA130759106H00000X
ORT221106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist