Provider Demographics
NPI:1386296317
Name:TIPTON, CHEYENNE MIKAYLAH
Entity type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:MIKAYLAH
Last Name:TIPTON
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 1:6644 GLADE AVE APT 212
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91303-2533
Mailing Address - Country:US
Mailing Address - Phone:818-337-8050
Mailing Address - Fax:
Practice Address - Street 1:5741 LAS VIRGENES RD STE A
Practice Address - Street 2:
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-1273
Practice Address - Country:US
Practice Address - Phone:818-712-8257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician