Provider Demographics
NPI:1649599531
Name:NIDA, TIMOTHY MATTHEW (MHR)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MATTHEW
Last Name:NIDA
Suffix:
Gender:M
Credentials:MHR
Other - Prefix:MR
Other - First Name:MATT
Other - Middle Name:
Other - Last Name:NIDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MHR
Mailing Address - Street 1:PO BOX 13
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0013
Mailing Address - Country:US
Mailing Address - Phone:918-658-5026
Mailing Address - Fax:
Practice Address - Street 1:39995 RND. MT LN
Practice Address - Street 2:
Practice Address - City:HOWE
Practice Address - State:OK
Practice Address - Zip Code:74940
Practice Address - Country:US
Practice Address - Phone:918-658-5026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK959101Y00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100731330-AMedicaid