Provider Demographics
NPI:1467658179
Name:FAUST, TIMOTHY PHILLIP (MSW)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:PHILLIP
Last Name:FAUST
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3
Mailing Address - Street 2:126 W BAYFIELD STREET
Mailing Address - City:WASHBURN
Mailing Address - State:WI
Mailing Address - Zip Code:54891-0003
Mailing Address - Country:US
Mailing Address - Phone:715-373-0480
Mailing Address - Fax:715-373-0480
Practice Address - Street 1:126 W BAYFIELD ST
Practice Address - Street 2:
Practice Address - City:WASHBURN
Practice Address - State:WI
Practice Address - Zip Code:54891-1182
Practice Address - Country:US
Practice Address - Phone:715-373-0480
Practice Address - Fax:715-373-0480
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2013-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WILCSW43521231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4220850Medicaid