Provider Demographics
NPI:1588757405
Name:FLYNN, TIMOTHY J (MS)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:FLYNN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 EAST GREEN BAY ST.,
Mailing Address - Street 2:STE. 191 SYNERGY COUNSELING SERVICES, SC
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-3881
Mailing Address - Country:US
Mailing Address - Phone:715-526-5466
Mailing Address - Fax:715-526-5545
Practice Address - Street 1:1415 EAST GREEN BAY ST.,
Practice Address - Street 2:STE 191 SYNERGY COUNSELING SERVICES, SC
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-3881
Practice Address - Country:US
Practice Address - Phone:715-526-5466
Practice Address - Fax:715-526-5545
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI653125101Y00000X
WI10996101Y00000X
WI653-125104100000X
WI10996-131104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
11678256OtherCAQH
WI39254500Medicaid