MEDICARE: MR. TIMOTHY JOHN ENEVOLDSEN M.ED., LPC, 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	101YP2500X	Professional Counselor	10727	TX
2	106H00000X	Marriage & Family Therapist	003822-042155	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851404206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TIMOTHY JOHN ENEVOLDSEN M.ED., LPC, LMFT

Provider Business Mailing Address
First Line	:	PO BOX 50291
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79159-0291
Country	:	US
Telephone Number	:	806-570-3775
Fax Number	:	806-356-8189

Provider Business Practice Location Address
First Line	:	6666 W AMARILLO BLVD
Second Line	:	SUITE 28
City	:	AMARILLO
State	:	TX
Zip	:	79106-1756
Country	:	US
Telephone Number	:	806-570-3775
Fax Number	:	806-356-8189

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

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	06/17/2008

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