Provider Demographics
NPI:1679716781
Name:SHIPON, RANDOLPH SCOTT (PHD, NCC, LPC)
Entity type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:SCOTT
Last Name:SHIPON
Suffix:
Gender:M
Credentials:PHD, NCC, LPC
Other - Prefix:DR
Other - First Name:WOLF
Other - Middle Name:
Other - Last Name:SHIPON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, NCC, LPC
Mailing Address - Street 1:5 DEER HILL CT
Mailing Address - Street 2:
Mailing Address - City:BOONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07005-1861
Mailing Address - Country:US
Mailing Address - Phone:215-906-3967
Mailing Address - Fax:
Practice Address - Street 1:550 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005-1168
Practice Address - Country:US
Practice Address - Phone:215-906-3967
Practice Address - Fax:973-300-1443
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00473800103T00000X
NY018363103T00000X
DEB1-0000832103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist