Provider Demographics
NPI:1114613973
Name:FOREMAN, TIMOTHY WAYNE
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:FOREMAN
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:PO BOX 73
Mailing Address - Street 2:
Mailing Address - City:OAKS
Mailing Address - State:OK
Mailing Address - Zip Code:74359-0073
Mailing Address - Country:US
Mailing Address - Phone:918-907-4142
Mailing Address - Fax:
Practice Address - Street 1:16414 W 760 RD
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-1675
Practice Address - Country:US
Practice Address - Phone:918-708-9009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No251K00000XAgenciesPublic Health or Welfare