Basic Information
Provider Information | |||||||||
NPI: | 1902183577 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE TIMOTHY CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11754 JOLLYVILLE RD STE 110 | ||||||||
Address2: |   | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787593948 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5123312700 | ||||||||
FaxNumber: | 5122195097 | ||||||||
Practice Location | |||||||||
Address1: | 11754 JOLLYVILLE RD STE 110 | ||||||||
Address2: |   | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787593948 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5123312700 | ||||||||
FaxNumber: | 5122195097 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2011 | ||||||||
LastUpdateDate: | 01/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MYERS | ||||||||
AuthorizedOfficialFirstName: | JIMMY | ||||||||
AuthorizedOfficialMiddleName: | KYLE | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER AND OPERATOR | ||||||||
AuthorizedOfficialTelephone: | 5123312700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD, LPC-S | ||||||||
NPICertificationDate: | 01/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 101YP2500X | 63765 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.