Provider Demographics
NPI:1376973321
Name:TIMOTHY J DAHEIM PA
Entity Type:Organization
Organization Name:TIMOTHY J DAHEIM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:254-773-0764
Mailing Address - Street 1:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76503-0204
Mailing Address - Country:US
Mailing Address - Phone:254-773-0764
Mailing Address - Fax:254-935-2258
Practice Address - Street 1:2407 S CLEAR CREEK RD
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-5721
Practice Address - Country:US
Practice Address - Phone:254-773-0764
Practice Address - Fax:254-935-2258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31399103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX347534501Medicaid
TX140806403Medicaid
TX140806403Medicaid