Provider Demographics
NPI:1164681979
Name:TIMOTHY NORRIS WEBSTER, PHD
Entity Type:Organization
Organization Name:TIMOTHY NORRIS WEBSTER, PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAMMI
Authorized Official - Middle Name:LYKINS
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-768-5348
Mailing Address - Street 1:160 KIMEL FOREST DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-714-6416
Mailing Address - Fax:336-714-6475
Practice Address - Street 1:160 KIMEL FOREST DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6074
Practice Address - Country:US
Practice Address - Phone:336-714-6416
Practice Address - Fax:336-714-6475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC635103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2820611Medicare PIN