Healthcare Provider Details

I. General information

NPI: 1962508911
Provider Name (Legal Business Name): TIMOTHY LYNN GOTH-OWENS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 EAST LANSING DRIVE
EAST LANSING MI
48823
US

IV. Provider business mailing address

2720 EAST LANSING DRIVE
EAST LANSING MI
48823
US

V. Phone/Fax

Practice location:
  • Phone: 517-337-2900
  • Fax: 517-351-1279
Mailing address:
  • Phone: 517-337-2900
  • Fax: 517-351-1279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301005809
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: