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NPI Code Detail

MEDICARE: MR. TIMOTHY CHARLES ROSENBOOM M. DIV.

MEDICARE: MR. TIMOTHY CHARLES ROSENBOOM M. DIV.
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
1101YA0400XAddiction (Substance Use Disorder) Counselor140001MI

General Provider Information

NPI Number : 1861560195
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. TIMOTHY CHARLES ROSENBOOM M. DIV.
Provider Business Mailing Address
First Line : 8848 KEPHART LN
Second Line :
City : BERRIEN SPRINGS
State : MI
Zip : 49103-1440
Country : US
Telephone Number : 269-471-1955
Fax Number :
Provider Business Practice Location Address
First Line : 960 E STATE ST
Second Line :
City : CASSOPOLIS
State : MI
Zip : 49031-9339
Country : US
Telephone Number : 269-476-9781
Fax Number : 269-476-9783
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/04/2006
Last Update Date : 07/08/2007

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