Provider Demographics
NPI:1306806476
Name:FRIESEN, TIMOTHY (PSYD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:FRIESEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30516
Mailing Address - Street 2:DEPT 6001A
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909-8016
Mailing Address - Country:US
Mailing Address - Phone:616-942-8060
Mailing Address - Fax:616-942-6690
Practice Address - Street 1:3355 EAGLE PARK DR NE
Practice Address - Street 2:STE 106
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-942-8060
Practice Address - Fax:616-942-6690
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007967103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical