Healthcare Provider Details

I. General information

NPI: 1235778911
Provider Name (Legal Business Name): TIMOTHY HUMBACH DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2019
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15520 19 MILE RD STE 450
CLINTON TOWNSHIP MI
48038-6332
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 586-416-2000
  • Fax: 586-416-2013
Mailing address:
  • Phone: 586-350-2644
  • Fax: 586-541-3735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501019446
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: