Healthcare Provider Details

I. General information

NPI: 1376788067
Provider Name (Legal Business Name): PAMELA JO TIPPEY-HERRICK LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16249 E RED MAPLE LN
LEWISTOWN IL
61542-9273
US

IV. Provider business mailing address

16249 E RED MAPLE LN
LEWISTOWN IL
61542-9273
US

V. Phone/Fax

Practice location:
  • Phone: 209-547-2117
  • Fax:
Mailing address:
  • Phone: 209-547-2117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180006970
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: