MEDICARE: TIMOTHY COLLISTER PHD, INC.

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	IMF51448	CA

General Provider Information

NPI Number	:	1932224987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIMOTHY COLLISTER PHD, INC.

Provider Business Mailing Address
First Line	:	13525 TRACY ST APT A
Second Line	:
City	:	BALDWIN PARK
State	:	CA
Zip	:	91706-4766
Country	:	US
Telephone Number	:	626-813-9548
Fax Number	:	626-813-9548

Provider Business Practice Location Address
First Line	:	7024 SEVILLE AVE STE D
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4969
Country	:	US
Telephone Number	:	323-588-9600
Fax Number	:	323-588-9696

Authorized Official
Title or Position	:	MFT INTERN
Name	:	KARLA ELIZABETH PEREZ
Credential	:	M.A.
Telephone Number	:	626-914-9609

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	08/22/2020

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