Provider Demographics
NPI:1528884251
Name:TRIPP, MARY SUZANN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUZANN
Last Name:TRIPP
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 1:604 BRENDA AVE
Mailing Address - Street 2:
Mailing Address - City:LORETTO
Mailing Address - State:TN
Mailing Address - Zip Code:38469-2377
Mailing Address - Country:US
Mailing Address - Phone:931-231-5321
Mailing Address - Fax:
Practice Address - Street 1:604 BRENDA AVE
Practice Address - Street 2:
Practice Address - City:LORETTO
Practice Address - State:TN
Practice Address - Zip Code:38469-2377
Practice Address - Country:US
Practice Address - Phone:931-231-5321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-24-395942106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician