Provider Demographics
NPI:1063706455
Name:TIMOTHY, MARY ELIZABETH (LPC)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:ELIZABETH
Last Name:TIMOTHY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 FORD RD STE 6
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-2824
Mailing Address - Country:US
Mailing Address - Phone:215-878-3400
Mailing Address - Fax:215-878-2082
Practice Address - Street 1:3905 FORD RD STE 6
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-2824
Practice Address - Country:US
Practice Address - Phone:215-878-3400
Practice Address - Fax:215-878-2082
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA23-1728027101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007283430002Medicaid