Healthcare Provider Details

I. General information

NPI: 1184622383
Provider Name (Legal Business Name): TRACY LEIGHTON TIPPETT LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TRACI LEANNE TIPPETT

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 NW 29TH CT
WILTON MANORS FL
33311-2436
US

IV. Provider business mailing address

800 NW 29TH CT
WILTON MANORS FL
33311-2436
US

V. Phone/Fax

Practice location:
  • Phone: 855-791-1662
  • Fax:
Mailing address:
  • Phone: 954-519-7675
  • Fax: 866-643-1382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17671
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW3620
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: