Provider Demographics
NPI:1568009777
Name:STORCK, TIMOTHY ADAM (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ADAM
Last Name:STORCK
Suffix:
Gender:M
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3114 SAN LUCAS AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-3422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2155 MARSH LN STE 132
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-5080
Practice Address - Country:US
Practice Address - Phone:940-595-4381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-19-36860103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-19-36860OtherBCBA LICENSE
TX2972OtherLBA