Provider Demographics
NPI:1992501803
Name:PERRY, TIMOTHY CARLTON
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:CARLTON
Last Name:PERRY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 REVERE ST APT 4
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-4419
Mailing Address - Country:US
Mailing Address - Phone:860-681-4163
Mailing Address - Fax:
Practice Address - Street 1:185 PILGRIM RD # SPAN106
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5324
Practice Address - Country:US
Practice Address - Phone:860-681-4163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASLP100570235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist