Healthcare Provider Details

I. General information

NPI: 1861560195
Provider Name (Legal Business Name): TIMOTHY CHARLES ROSENBOOM M. DIV.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 E STATE ST
CASSOPOLIS MI
49031-9339
US

IV. Provider business mailing address

8848 KEPHART LN
BERRIEN SPRINGS MI
49103-1440
US

V. Phone/Fax

Practice location:
  • Phone: 269-476-9781
  • Fax: 269-476-9783
Mailing address:
  • Phone: 269-471-1955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number140001
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: