Provider Demographics
NPI:1275637316
Name:RICHTER, TIMOTHY JON (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JON
Last Name:RICHTER
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 1:1121 SE DOCK ST
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-4067
Mailing Address - Country:US
Mailing Address - Phone:360-682-6499
Mailing Address - Fax:
Practice Address - Street 1:1121 SE DOCK ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-4067
Practice Address - Country:US
Practice Address - Phone:360-682-6499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY-60502608103T00000X
AZ1451103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT75931OtherBLUE CROSS BLUE SHIELD
MT254254Medicaid