Healthcare Provider Details

I. General information

NPI: 1790358547
Provider Name (Legal Business Name): MELANIE M TIPTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELANIE M BURRIS

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1628 OKLAHOMA AVE
TRENTON MO
64683-2565
US

IV. Provider business mailing address

1601 OLD SOUTH RIVER RD
SAINT CHARLES MO
63303-4120
US

V. Phone/Fax

Practice location:
  • Phone: 660-359-4600
  • Fax: 660-359-4286
Mailing address:
  • Phone: 636-224-1210
  • Fax: 636-946-1008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2023033282
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: