Provider Demographics
NPI:1326466582
Name:HERLIHY, TIMOTHY OLIVER (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:OLIVER
Last Name:HERLIHY
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11611 MISTY MOSS CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4250
Mailing Address - Country:US
Mailing Address - Phone:314-552-1224
Mailing Address - Fax:
Practice Address - Street 1:3026 LACLEDE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2136
Practice Address - Country:US
Practice Address - Phone:314-340-5988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110308462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer