=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104463462
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMONIKA SHAREE TIPTON LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2019
-----------------------------------------------------
Last Update Date | 10/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6035 EXECUTIVE DR STE 204
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48911-5338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-627-7669
-----------------------------------------------------
Fax | 734-627-6001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6035 EXECUTIVE DR STE 204
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48911-5338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-627-7669
-----------------------------------------------------
Fax | 734-627-6001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801108720
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------