Provider Demographics
NPI:1417660630
Name:HARRISON, TIMOTHY ANDREW
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ANDREW
Last Name:HARRISON
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 1:9808 VENICE BLVD STE 505
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-6818
Mailing Address - Country:US
Mailing Address - Phone:310-945-3350
Mailing Address - Fax:
Practice Address - Street 1:265 S ANITA DR STE 102-104
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3355
Practice Address - Country:US
Practice Address - Phone:310-945-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker