Provider Demographics
NPI:1609407295
Name:MCNELIS, TIM
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:MCNELIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 7TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-5914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 7TH AVE SW
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-5914
Practice Address - Country:US
Practice Address - Phone:507-210-0141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-01
Last Update Date:2020-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherFAMILY COUNSELING