Provider Demographics
NPI:1962265595
Name:ICE, TIMOTHY DWANE (LMFT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DWANE
Last Name:ICE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3313 GREENHAM DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-7153
Mailing Address - Country:US
Mailing Address - Phone:910-366-1024
Mailing Address - Fax:
Practice Address - Street 1:3313 GREENHAM DR
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-7153
Practice Address - Country:US
Practice Address - Phone:910-366-1024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205379106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist