Provider Demographics
NPI:1073105045
Name:TIMBERLAKE, THERESA (LSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:TIMBERLAKE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7031 CORPORATE WAY STE 103
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7031 CORPORATE WAY STE 103
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4262
Practice Address - Country:US
Practice Address - Phone:937-619-9089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.20046681041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker