Provider Demographics
NPI:1437419322
Name:KRESIEN, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:KRESIEN
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 1:1599 J ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS AFB
Mailing Address - State:ND
Mailing Address - Zip Code:58205-6332
Mailing Address - Country:US
Mailing Address - Phone:701-747-4460
Mailing Address - Fax:
Practice Address - Street 1:1599 J ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS AFB
Practice Address - State:ND
Practice Address - Zip Code:58205
Practice Address - Country:US
Practice Address - Phone:701-747-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-24
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MN8615104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker