Provider Demographics
NPI:1104535103
Name:FLYNN, TIMOTHY EDWARD (BA PHILOSOPHY, CRM)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:EDWARD
Last Name:FLYNN
Suffix:
Gender:M
Credentials:BA PHILOSOPHY, CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 JACKSON ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-3244
Mailing Address - Country:US
Mailing Address - Phone:541-967-8545
Mailing Address - Fax:
Practice Address - Street 1:1100 JACKSON ST SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-3244
Practice Address - Country:US
Practice Address - Phone:541-967-8545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR106697101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)