MEDICARE: TIMOTHY IRVING

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	LPC012828	GA

General Provider Information

NPI Number	:	1225801939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY IRVING

Provider Business Mailing Address
First Line	:	2110 GARDEN PL
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30316-2948
Country	:	US
Telephone Number	:	404-545-7202
Fax Number	:

Provider Business Practice Location Address
First Line	:	2110 GARDEN PL
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30316-2948
Country	:	US
Telephone Number	:	404-436-0730
Fax Number	:

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

Provider Enumeration Date	:	11/03/2023
Last Update Date	:	11/03/2023

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