Healthcare Provider Details

I. General information

NPI: 1568794493
Provider Name (Legal Business Name): TIMOTHY A URBIN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 04/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 MEDICAL PARK BLVD
BRISTOL TN
37620-7343
US

IV. Provider business mailing address

PO BOX 699
MOUNTAIN HOME TN
37684-0699
US

V. Phone/Fax

Practice location:
  • Phone: 423-989-4050
  • Fax: 423-990-3044
Mailing address:
  • Phone: 423-989-4050
  • Fax: 423-989-3044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberP1987
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP1987
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: