MEDICARE: MR. CHARLES TIPTON MS, LCPC

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	101YP2500X	Professional Counselor	180.005533	IL

General Provider Information

NPI Number	:	1255628038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES TIPTON MS, LCPC

Provider Business Mailing Address
First Line	:	1809 W GRAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-7716
Country	:	US
Telephone Number	:	312-371-4095
Fax Number	:	312-344-1054

Provider Business Practice Location Address
First Line	:	2528 N LINCOLN AVE
Second Line	:	SUITE 116
City	:	CHICAGO
State	:	IL
Zip	:	60614-2333
Country	:	US
Telephone Number	:	312-371-4095
Fax Number	:	312-344-1054

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

Provider Enumeration Date	:	06/30/2011
Last Update Date	:	07/19/2011

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