Provider Demographics
NPI:1184622383
Name:TIPPETT, TRACY LEIGHTON (LCSW)
Entity type:Individual
Prefix:MR
First Name:TRACY
Middle Name:LEIGHTON
Last Name:TIPPETT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:LEANNE
Other - Last Name:TIPPETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 NW 29TH CT
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33311-2436
Mailing Address - Country:US
Mailing Address - Phone:954-519-7675
Mailing Address - Fax:866-643-1382
Practice Address - Street 1:800 NW 29TH CT
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33311-2436
Practice Address - Country:US
Practice Address - Phone:855-791-1662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC176711041C0700X
TNLSW36201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3922967Medicaid
TN103I800270Medicare PIN
TN3922968Medicare ID - Type Unspecified