Provider Demographics
NPI:1609924216
Name:PORTINGA, TIM RICHARD (PSYD LP)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:RICHARD
Last Name:PORTINGA
Suffix:
Gender:M
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11505 36TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2304
Mailing Address - Country:US
Mailing Address - Phone:763-509-3818
Mailing Address - Fax:763-559-0149
Practice Address - Street 1:11505 36TH AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2304
Practice Address - Country:US
Practice Address - Phone:763-509-3818
Practice Address - Fax:763-559-0149
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4699103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical