Provider Demographics
NPI:1619195997
Name:WAHLBERG, TIMOTHY JAMES (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:WAHLBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 HANCOCK AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-3269
Mailing Address - Country:US
Mailing Address - Phone:847-622-1509
Mailing Address - Fax:
Practice Address - Street 1:65 N RIVER LN
Practice Address - Street 2:SUITE 204
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4519
Practice Address - Country:US
Practice Address - Phone:630-845-9644
Practice Address - Fax:630-845-9678
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent