Healthcare Provider Details

I. General information

NPI: 1063558690
Provider Name (Legal Business Name): TIMOTHY J UNDERWOOD LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

936 MARKET ST
PARKERSBURG WV
26101-4737
US

IV. Provider business mailing address

936 MARKET ST
PARKERSBURG WV
26101-4737
US

V. Phone/Fax

Practice location:
  • Phone: 304-422-7300
  • Fax: 304-428-3719
Mailing address:
  • Phone: 304-422-7300
  • Fax: 304-428-3719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1670
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: