Provider Demographics
NPI:1578288510
Name:NOVAK, TIMOTHY ROBERT (LLMSW)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ROBERT
Last Name:NOVAK
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 MADISON AVE SE APT 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4617
Mailing Address - Country:US
Mailing Address - Phone:616-901-9549
Mailing Address - Fax:
Practice Address - Street 1:1324 LAKE DR SE STE 8
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1673
Practice Address - Country:US
Practice Address - Phone:616-901-9549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801107413104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker