Provider Demographics
NPI:1093827776
Name:TIPTON, MARK ALLEN (PSY D)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:TIPTON
Suffix:
Gender:
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2032 10TH AVE SUITE 4
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015
Mailing Address - Country:US
Mailing Address - Phone:806-476-1440
Mailing Address - Fax:806-476-1450
Practice Address - Street 1:2032 10TH AVE SUITE 4
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015
Practice Address - Country:US
Practice Address - Phone:806-476-1440
Practice Address - Fax:806-476-1450
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38919101YM0800X, 103TC0700X
WV1144101YM0800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001722829OtherBCBS