Healthcare Provider Details

I. General information

NPI: 1194209635
Provider Name (Legal Business Name): KAITLYN TIMBROOK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1349 E STROOP RD
DAYTON OH
45429-4929
US

IV. Provider business mailing address

1349 E STROOP RD
DAYTON OH
45429-4929
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-1115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.1902362
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: