Provider Demographics
NPI:1124149315
Name:LIDDY, TIMOTHY P (HAD)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:P
Last Name:LIDDY
Suffix:
Gender:M
Credentials:HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8800 SE SUNNYSIDE RD.
Mailing Address - Street 2:STE. 300-N
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5738
Mailing Address - Country:US
Mailing Address - Phone:503-659-5115
Mailing Address - Fax:816-792-9819
Practice Address - Street 1:42382 BOB HOPE DRIVE
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270
Practice Address - Country:US
Practice Address - Phone:760-341-9619
Practice Address - Fax:314-839-5215
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005030823237700000X
CA7721237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist