Provider Demographics
NPI:1003338450
Name:FELLIN, TIMOTHY
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:FELLIN
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 1:11004 SW 30TH PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8801 LIPAN ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80260
Practice Address - Country:US
Practice Address - Phone:303-657-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10011653002OtherPROVIDENCE HEALTH PLAN