Provider Demographics
NPI:1962773754
Name:TIPTON, MARY EMALIE (LMHC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:EMALIE
Last Name:TIPTON
Suffix:
Gender:
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 AMORAK RD
Mailing Address - Street 2:
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87557-8720
Mailing Address - Country:US
Mailing Address - Phone:575-224-1112
Mailing Address - Fax:
Practice Address - Street 1:2055 S PACHECO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3997
Practice Address - Country:US
Practice Address - Phone:505-702-8112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2023-0901101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional