=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407312739
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZENN TIMMER LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2019
-----------------------------------------------------
Last Update Date | 03/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 331 E STATE RD RM N8
-----------------------------------------------------
City | GRANT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49327-8504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-342-3762
-----------------------------------------------------
Fax | 231-834-5186
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 COBB ST
-----------------------------------------------------
City | CADILLAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49601-2588
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-876-6527
-----------------------------------------------------
Fax | 231-876-6519
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801109015
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------