Provider Demographics
NPI:1407912462
Name:TIMOTHY COLLISTER PHD & ASSOCIATES, INC
Entity Type:Organization
Organization Name:TIMOTHY COLLISTER PHD & ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:COLLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:323-588-9600
Mailing Address - Street 1:1441 HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4512
Mailing Address - Country:US
Mailing Address - Phone:323-588-9600
Mailing Address - Fax:
Practice Address - Street 1:7024 SEVILLE AVE STE D
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4969
Practice Address - Country:US
Practice Address - Phone:323-588-9600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12985103T00000X
CAPSY12895103TC2200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY128951Medicaid
CAPSY12950Medicaid