MEDICARE: AMY A KIPP LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	T0879	OR
2	106H00000X	Marriage & Family Therapist	202277	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12684503	OTHER	TX	CAQH

General Provider Information

NPI Number	:	1255686812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY A KIPP LMFT

Provider Business Mailing Address
First Line	:	11467 HUEBNER RD STE 251
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-1073
Country	:	US
Telephone Number	:	503-389-5504
Fax Number	:

Provider Business Practice Location Address
First Line	:	11467 HUEBNER RD STE 251
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-1073
Country	:	US
Telephone Number	:	503-389-5504
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2012
Last Update Date	:	04/17/2019

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Directions to “ AMY A KIPP LMFT” Practice Location

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