Provider Demographics
NPI:1851307946
Name:WAHL, TIMOTHY E (PHD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:E
Last Name:WAHL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 C AVE E
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-4246
Mailing Address - Country:US
Mailing Address - Phone:641-672-3159
Mailing Address - Fax:641-672-3259
Practice Address - Street 1:1229 C AVE E
Practice Address - Street 2:#300
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-4246
Practice Address - Country:US
Practice Address - Phone:641-672-3159
Practice Address - Fax:641-672-3259
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAI9827103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI9827OtherINDIVIDUAL LICENSE
IAI9827OtherINDIVIDUAL LICENSE