MEDICARE: TIMOTHY HOLSATHER LMFT

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	106H00000X	Marriage & Family Therapist	1599	NC

General Provider Information

NPI Number	:	1194065441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY HOLSATHER LMFT

Provider Business Mailing Address
First Line	:	1921 PRESTWICK LN
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28405-4129
Country	:	US
Telephone Number	:	910-616-2156
Fax Number	:

Provider Business Practice Location Address
First Line	:	624 US HIGHWAY 17 S
Second Line	:	STE. 2
City	:	HOLLY RIDGE
State	:	NC
Zip	:	28445-8660
Country	:	US
Telephone Number	:	910-616-2156
Fax Number	:

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

Provider Enumeration Date	:	02/25/2013
Last Update Date	:	07/14/2014

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