Provider Demographics
NPI:1114097003
Name:DURICK, TIMOTHY DANE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DANE
Last Name:DURICK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5957 S MOONEY BLVD
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-9394
Mailing Address - Country:US
Mailing Address - Phone:559-737-4669
Mailing Address - Fax:559-737-4697
Practice Address - Street 1:5957 S MOONEY BLVD
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-9394
Practice Address - Country:US
Practice Address - Phone:559-733-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16229103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q07791Medicare UPIN
CA0PL162290Medicare ID - Type Unspecified