Provider Demographics
NPI:1811632037
Name:SIPPEL, TRACI SHUTTLESWORTH
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:SHUTTLESWORTH
Last Name:SIPPEL
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 1:11427 REED HARTMAN HWY STE 119
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45241-2418
Mailing Address - Country:US
Mailing Address - Phone:513-443-8790
Mailing Address - Fax:
Practice Address - Street 1:11427 REED HARTMAN HWY STE 119
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45241-2418
Practice Address - Country:US
Practice Address - Phone:513-443-8790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-02
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2404064101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional