MEDICARE: SHELSEA MAGAN TIPPEN BCBA, LBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	7205	TX
2	103K00000X	Behavior Analyst	2017028783	MO
3	103K00000X	Behavior Analyst	1-19-37807

General Provider Information

NPI Number	:	1164066114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELSEA MAGAN TIPPEN BCBA, LBA

Provider Business Mailing Address
First Line	:	4201 BRIDGEVIEW DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-9571
Country	:	US
Telephone Number	:	573-625-1724
Fax Number	:

Provider Business Practice Location Address
First Line	:	4201 BRIDGEVIEW DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-9571
Country	:	US
Telephone Number	:	817-369-3092
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2019
Last Update Date	:	07/31/2024

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