Provider Demographics
NPI:1225801939
Name:IRVING, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:IRVING
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 1:2110 GARDEN PL
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2948
Mailing Address - Country:US
Mailing Address - Phone:404-545-7202
Mailing Address - Fax:
Practice Address - Street 1:2110 GARDEN PL
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-2948
Practice Address - Country:US
Practice Address - Phone:404-436-0730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012828101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health