Provider Demographics
NPI:1871100719
Name:TIPHARETH, SHANNAN
Entity type:Individual
Prefix:
First Name:SHANNAN
Middle Name:
Last Name:TIPHARETH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3470 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1520
Mailing Address - Country:US
Mailing Address - Phone:719-369-3781
Mailing Address - Fax:
Practice Address - Street 1:3470 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1520
Practice Address - Country:US
Practice Address - Phone:719-369-3781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACB.0008677101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)