Provider Demographics
NPI:1396231544
Name:DEMICH, TIMITHY (CDCA)
Entity Type:Individual
Prefix:
First Name:TIMITHY
Middle Name:
Last Name:DEMICH
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4930 ENTERPRISE DR NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44481-8706
Mailing Address - Country:US
Mailing Address - Phone:330-787-0955
Mailing Address - Fax:
Practice Address - Street 1:4930 ENTERPRISE DR NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44481-8706
Practice Address - Country:US
Practice Address - Phone:330-787-0955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH167731324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility