Healthcare Provider Details

I. General information

NPI: 1962544486
Provider Name (Legal Business Name): TIMOTHY KEITH DECHENNE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 E COOLEY DR
COLTON CA
92324-3905
US

IV. Provider business mailing address

PO BOX 56492
RIVERSIDE CA
92517-1392
US

V. Phone/Fax

Practice location:
  • Phone: 909-423-0750
  • Fax: 909-423-0760
Mailing address:
  • Phone: 909-423-0750
  • Fax: 909-423-0760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY6663
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: