Healthcare Provider Details

I. General information

NPI: 1558450809
Provider Name (Legal Business Name): TIMOTHY HARPER COLVIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 BRISTOL ST SUITE A207
COSTA MESA CA
92626-5981
US

IV. Provider business mailing address

1504 BROOKHOLLOW DR SUITE 111
SANTA ANA CA
92705-5418
US

V. Phone/Fax

Practice location:
  • Phone: 949-290-4922
  • Fax:
Mailing address:
  • Phone: 714-957-1004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 44052
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: