Healthcare Provider Details

I. General information

NPI: 1932207164
Provider Name (Legal Business Name): SHILO RENAE TIPPETT PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 NE A ST
MADRAS OR
97741-1844
US

IV. Provider business mailing address

480 NE A ST
MADRAS OR
97741-1844
US

V. Phone/Fax

Practice location:
  • Phone: 541-475-4800
  • Fax:
Mailing address:
  • Phone: 541-475-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2217
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: