Provider Demographics
NPI:1083710800
Name:EATON, TIMOTHY TRELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:TRELL
Last Name:EATON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 4TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-2912
Mailing Address - Country:US
Mailing Address - Phone:701-839-0474
Mailing Address - Fax:701-839-0713
Practice Address - Street 1:1705 4TH AVE NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-2912
Practice Address - Country:US
Practice Address - Phone:701-839-0474
Practice Address - Fax:701-839-0713
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND190103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16943Medicaid
ND5297OtherBLUE CROSS BLUE SHIELD
ND90688OtherSS DISABILITY DETERMINATI
NDN5297Medicare ID - Type Unspecified
ND90688OtherSS DISABILITY DETERMINATI