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General NPI Number Information
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NPI Number | 1407912462
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Entity Type | Organization
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Legal Business Name | TIMOTHY COLLISTER PHD & ASSOCIATES, INC
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Dates
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Enumeration Date | 12/27/2006
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Last Update Date | 11/27/2007
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Provider Practice Location Address
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Address Line | 7024 SEVILLE AVE STE D
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City | HUNTINGTON PARK
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State | CA
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Zip | 90255-4969
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Country | US
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Telephone | 323-588-9600
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Fax |
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Provider Business Mailing Address
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Address Line | 1441 HUNTINGTON DR
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City | SOUTH PASADENA
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State | CA
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Zip | 91030-4512
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Country | US
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Telephone | 323-588-9600
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | TIMOTHY D COLLISTER
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Credential | PHD
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Telephone | 323-588-9600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | PSY12895
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103TF0000X
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Taxonomy Name | Family Psychologist
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License Number | PSY12895
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY12985
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License Number State | CA
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