Healthcare Provider Details

I. General information

NPI: 1760702740
Provider Name (Legal Business Name): RONALD LEE TIMMCKE M.A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2010
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4253 MONTGOMERY BLVD NE SUITE 220
ALBUQUERQUE NM
87109-1106
US

IV. Provider business mailing address

13204 SILVER PEAK PL NE
ALBUQUERQUE NM
87111-8261
US

V. Phone/Fax

Practice location:
  • Phone: 505-342-0400
  • Fax: 505-342-0500
Mailing address:
  • Phone: 505-850-7301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3907
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2741
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: