Healthcare Provider Details

I. General information

NPI: 1801441092
Provider Name (Legal Business Name): TIMOTHY R CHITWOOD CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 GRAND RIVER AVE
DETROIT MI
48204-2139
US

IV. Provider business mailing address

15122 UNIVERSITY ST
ALLEN PARK MI
48101-3023
US

V. Phone/Fax

Practice location:
  • Phone: 313-834-5930
  • Fax:
Mailing address:
  • Phone: 734-828-3621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: