Provider Demographics
NPI:1265045439
Name:TIMBERLAKE, MAI
Entity type:Individual
Prefix:
First Name:MAI
Middle Name:
Last Name:TIMBERLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11549 LOS OSOS VALLEY RD STE 207
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-6456
Mailing Address - Country:US
Mailing Address - Phone:805-316-1136
Mailing Address - Fax:
Practice Address - Street 1:11549 LOS OSOS VALLEY RD STE 207
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-6456
Practice Address - Country:US
Practice Address - Phone:805-316-1136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-27
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA146069106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist