Healthcare Provider Details

I. General information

NPI: 1477910982
Provider Name (Legal Business Name): TIMOTHY MCDIVITT MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2016
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 E US HIGHWAY 52
RUSHVILLE IN
46173-7901
US

IV. Provider business mailing address

645 S ROGERS ST
BLOOMINGTON IN
47403-2353
US

V. Phone/Fax

Practice location:
  • Phone: 765-932-3974
  • Fax: 765-932-3576
Mailing address:
  • Phone: 812-339-1691
  • Fax: 812-337-2438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87000710A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34007445A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: