Provider Demographics
NPI:1588104442
Name:CORDELL, TIMOTHY (BCBA, LBA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:CORDELL
Suffix:
Gender:M
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4127 CANTON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-1918
Mailing Address - Country:US
Mailing Address - Phone:248-299-0030
Mailing Address - Fax:
Practice Address - Street 1:4127 CANTON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1918
Practice Address - Country:US
Practice Address - Phone:248-812-6809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-26
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133003665103K00000X
MI7401002470103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst