Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) |
NPI | 1003338450 |
---|---|
Provider Name | Mr. Timothy Fellin |
First Address | Portland, OR 97219 |
Second Address | Thornton, CO 80260 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2017 |
Last Update Date | 07/07/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
10011653002 | PROVIDENCE HEALTH PLAN (01) | OR |