Provider Demographics
NPI:1518696111
Name:SCARBROUGH, TIMOTHY WAYNE (LLC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:SCARBROUGH
Suffix:
Gender:M
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41550 E ANN ARBOR TRL
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4308
Mailing Address - Country:US
Mailing Address - Phone:734-207-5207
Mailing Address - Fax:
Practice Address - Street 1:41550 E ANN ARBOR TRL
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4308
Practice Address - Country:US
Practice Address - Phone:734-207-5207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 101YP1600X, 103TC2200X, 103TB0200X, 106H00000X, 101YP2500X
MI6362009537103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling