Healthcare Provider Details

I. General information

NPI: 1366576860
Provider Name (Legal Business Name): TIMOTHY LIONETTI PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 S STATE ST
CLARKS SUMMIT PA
18411-1684
US

IV. Provider business mailing address

PO BOX 32
CLARKS SUMMIT PA
18411-0032
US

V. Phone/Fax

Practice location:
  • Phone: 570-585-2927
  • Fax:
Mailing address:
  • Phone: 570-585-2927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPS015638
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: