MEDICARE: MR. TIMOTHY D SOLOMON IMH 16596

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	16596	FL

General Provider Information

NPI Number	:	1053935981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TIMOTHY D SOLOMON IMH 16596

Provider Business Mailing Address
First Line	:	13417 LITTLE GEM CIR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33913-7924
Country	:	US
Telephone Number	:	239-462-2204
Fax Number	:

Provider Business Practice Location Address
First Line	:	12557 NEW BRITTANY BLVD STE 31-2
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3651
Country	:	US
Telephone Number	:	239-939-5504
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2020
Last Update Date	:	06/06/2020

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