Provider Demographics
NPI:1083479471
Name:EARLS, TIMOTHY CLYDE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:CLYDE
Last Name:EARLS
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 ROSETTA ST
Mailing Address - Street 2:
Mailing Address - City:NEW LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45345-1519
Mailing Address - Country:US
Mailing Address - Phone:937-681-8318
Mailing Address - Fax:
Practice Address - Street 1:407 AMBROSE CT
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-1556
Practice Address - Country:US
Practice Address - Phone:937-542-5680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.03787235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist