MEDICARE: TIMOTHY DURHAM LISW-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I-000862-S	OH

General Provider Information

NPI Number	:	1134644016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY DURHAM LISW-S

Provider Business Mailing Address
First Line	:	44 SHADY LN
Second Line	:
City	:	GRANVILLE
State	:	OH
Zip	:	43023-9281
Country	:	US
Telephone Number	:	740-739-2903
Fax Number	:

Provider Business Practice Location Address
First Line	:	905 RIVER RD
Second Line	:
City	:	GRANVILLE
State	:	OH
Zip	:	43023-9560
Country	:	US
Telephone Number	:	740-507-6707
Fax Number	:	740-739-2906

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2017
Last Update Date	:	08/11/2017

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