Healthcare Provider Details

I. General information

NPI: 1104771831
Provider Name (Legal Business Name): TIMOTHY HOLLERN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2026
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 CASCADE RD SE STE 3
GRAND RAPIDS MI
49546-8384
US

IV. Provider business mailing address

277 RIVER PINE DR
LOWELL MI
49331-9574
US

V. Phone/Fax

Practice location:
  • Phone: 616-202-4840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: