Provider Demographics
NPI:1346941119
Name:COSTON, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:COSTON
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 1:401 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-4040
Mailing Address - Country:US
Mailing Address - Phone:919-325-5825
Mailing Address - Fax:
Practice Address - Street 1:401 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-4040
Practice Address - Country:US
Practice Address - Phone:919-325-5825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-22-229598106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician