MEDICARE: SHANTA RENAE TIPTON MMT

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	225700000X	Massage Therapist	302040	KY

General Provider Information

NPI Number	:	1922930122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTA RENAE TIPTON MMT

Provider Business Mailing Address
First Line	:	301 3RD ST
Second Line	:
City	:	RAVENNA
State	:	KY
Zip	:	40472-1410
Country	:	US
Telephone Number	:	859-408-3776
Fax Number	:

Provider Business Practice Location Address
First Line	:	114 E MAIN ST
Second Line	:
City	:	RICHMOND
State	:	KY
Zip	:	40475-1986
Country	:	US
Telephone Number	:	859-408-3776
Fax Number	:

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

Provider Enumeration Date	:	06/01/2026
Last Update Date	:	06/01/2026

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