Provider Demographics
NPI:1477687747
Name:TIMBERLAKE, JULIE L (PT)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:L
Last Name:TIMBERLAKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12611 ECKEL JUNCTION RD
Mailing Address - Street 2:SUITE 1H
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-1304
Mailing Address - Country:US
Mailing Address - Phone:419-491-7150
Mailing Address - Fax:419-745-8819
Practice Address - Street 1:1502 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-1838
Practice Address - Country:US
Practice Address - Phone:419-491-7150
Practice Address - Fax:419-745-8819
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25637225100000X, 2251X0800X
OHPT.012977225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT256370Medicare ID - Type Unspecified
OH4309391Medicare PIN