Provider Demographics
NPI:1437332319
Name:MODER, TIMOTHY JAMES (SAC-IT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
Last Name:MODER
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-6730
Mailing Address - Country:US
Mailing Address - Phone:218-940-3518
Mailing Address - Fax:
Practice Address - Street 1:1507 TOWER AVE
Practice Address - Street 2:# 307
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-2532
Practice Address - Country:US
Practice Address - Phone:715-392-9300
Practice Address - Fax:715-392-8041
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14242-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)