Healthcare Provider Details

I. General information

NPI: 1952088429
Provider Name (Legal Business Name): TIMOTHY ARTHUR BIRD SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W3272 WOLF RIVER DRIVE
KESHENA WI
54135-9202
US

IV. Provider business mailing address

P.O BOX 280
KESHENA WI
54135-0280
US

V. Phone/Fax

Practice location:
  • Phone: 715-799-3861
  • Fax: 715-799-3517
Mailing address:
  • Phone: 715-799-3861
  • Fax: 715-799-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: