Provider Demographics
NPI:1104463462
Name:TIPTON, DOMONIKA SHAREE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:DOMONIKA
Middle Name:SHAREE
Last Name:TIPTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6035 EXECUTIVE DR STE 204
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-5338
Mailing Address - Country:US
Mailing Address - Phone:734-627-7669
Mailing Address - Fax:734-627-6001
Practice Address - Street 1:6035 EXECUTIVE DR STE 204
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-5338
Practice Address - Country:US
Practice Address - Phone:734-627-7669
Practice Address - Fax:734-627-6001
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MI68011087201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker