Provider Demographics
NPI:1366588964
Name:SHREVE, TIMOTHY MARSHALL (PT)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MARSHALL
Last Name:SHREVE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 DUNSTABLE LANE
Mailing Address - Street 2:
Mailing Address - City:PONTA VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-7050
Mailing Address - Country:US
Mailing Address - Phone:904-217-4314
Mailing Address - Fax:
Practice Address - Street 1:9100 MERRILL RD
Practice Address - Street 2:SUITE #10
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-4358
Practice Address - Country:US
Practice Address - Phone:904-725-9994
Practice Address - Fax:904-725-9138
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20104225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887834000Medicaid