MEDICARE: KATHY L. TIPPS PH.D.

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	103TC0700X	Clinical Psychologist	2-5443	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00U95P	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1598777013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHY L. TIPPS PH.D.

Provider Business Mailing Address
First Line	:	3131 TURTLE CREEK BLVD
Second Line	:	SUITE 1026
City	:	DALLAS
State	:	TX
Zip	:	75219-5426
Country	:	US
Telephone Number	:	214-522-0931
Fax Number	:	214-522-2507

Provider Business Practice Location Address
First Line	:	3131 TURTLE CREEK BLVD
Second Line	:	SUITE 1026
City	:	DALLAS
State	:	TX
Zip	:	75219-5426
Country	:	US
Telephone Number	:	214-522-0931
Fax Number	:	214-522-2507

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

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	07/08/2007

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