=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407065758
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA M TIMM PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 05/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4590 WELLINGTON DR
-----------------------------------------------------
City | OKEMOS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48864-1245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-803-8099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4590 WELLINGTON DR
-----------------------------------------------------
City | OKEMOS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48864-1245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-803-8099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 4101006323
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801065390
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------