Healthcare Provider Details

I. General information

NPI: 1063184752
Provider Name (Legal Business Name): TIMOTHY CONNELL HARMON MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2021
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1433 S ROBERTSON BLVD
LOS ANGELES CA
90035-3414
US

IV. Provider business mailing address

1433 S ROBERTSON BLVD
LOS ANGELES CA
90035-3414
US

V. Phone/Fax

Practice location:
  • Phone: 310-785-2121
  • Fax:
Mailing address:
  • Phone: 310-785-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number106822
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: