Basic Information
| Provider Information | |||||||||
| NPI: | 1285688622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VONENGELN | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7687 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652057687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738822259 | ||||||||
| FaxNumber: | 5738848526 | ||||||||
| Practice Location | |||||||||
| Address1: | 1805 E WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737777500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 05/24/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW000347 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 496787011 | 05 | MO | MEDICAID | 800007095 | 01 | MO | RR MEDICARE | OTHER |