Provider Demographics
NPI:1154779783
Name:MACEYKO, TIMOTHY BYRON (LCDCII)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:BYRON
Last Name:MACEYKO
Suffix:
Gender:M
Credentials:LCDCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-1736
Mailing Address - Country:US
Mailing Address - Phone:740-914-5000
Mailing Address - Fax:740-914-5030
Practice Address - Street 1:206 S PROSPECT ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-3922
Practice Address - Country:US
Practice Address - Phone:740-244-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCII.161582101YA0400X
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist