Healthcare Provider Details

I. General information

NPI: 1356413652
Provider Name (Legal Business Name): DONALD SHANE TIPTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W COMMONWEALTH AVE
FULLERTON CA
92832-1810
US

IV. Provider business mailing address

3554 W CHRISTINE CIR APT 3
ANAHEIM CA
92804-4640
US

V. Phone/Fax

Practice location:
  • Phone: 714-447-7000
  • Fax: 714-447-7003
Mailing address:
  • Phone: 714-995-2705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: