Healthcare Provider Details

I. General information

NPI: 1669868949
Provider Name (Legal Business Name): TIMOTHY TIVEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2381 OSPREY LN
KELSO WA
98626-5408
US

IV. Provider business mailing address

2381 OSPREY LN
KELSO WA
98626-5408
US

V. Phone/Fax

Practice location:
  • Phone: 360-636-4606
  • Fax:
Mailing address:
  • Phone: 360-636-4606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: