Healthcare Provider Details

I. General information

NPI: 1245821461
Provider Name (Legal Business Name): GRACE A TIPPY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2021
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 MAIN ST NE UNIT 223
FRIDLEY MN
55432-4585
US

IV. Provider business mailing address

6000 MAIN ST NE UNIT 223
FRIDLEY MN
55432-4585
US

V. Phone/Fax

Practice location:
  • Phone: 651-230-1315
  • Fax:
Mailing address:
  • Phone: 651-230-1315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number305950
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: