Provider Demographics
NPI:1619844644
Name:SMITH, TIMOTHY JAMES
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4723 HARTEL RD LOT 16
Mailing Address - Street 2:
Mailing Address - City:POTTERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48876-9779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:131 1/2 S COCHRAN AVE STE A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1509
Practice Address - Country:US
Practice Address - Phone:517-667-7543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-23
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI75501011942225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist