Provider Demographics
NPI:1568546588
Name:TIMBERLAKE, HOLLY J (PHD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:J
Last Name:TIMBERLAKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 W STREETSBORO ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-2850
Mailing Address - Country:US
Mailing Address - Phone:330-653-5081
Mailing Address - Fax:330-653-5823
Practice Address - Street 1:10 W STREETSBORO ST
Practice Address - Street 2:SUITE 302
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44236-2850
Practice Address - Country:US
Practice Address - Phone:330-653-5081
Practice Address - Fax:330-653-5823
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0001997101YM0800X
OH5562103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHTICP23422Medicare PIN