Provider Demographics
NPI:1679195960
Name:WOOTEN, TIMOTHY JERREAL (LCMHC-A, LCAS-A, NCC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JERREAL
Last Name:WOOTEN
Suffix:
Gender:M
Credentials:LCMHC-A, LCAS-A, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 BALMORAY CT APT 5
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2004
Mailing Address - Country:US
Mailing Address - Phone:336-504-3384
Mailing Address - Fax:
Practice Address - Street 1:3708 LYCKAN PKWY STE 205
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2586
Practice Address - Country:US
Practice Address - Phone:919-809-9846
Practice Address - Fax:919-516-0057
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25834101YA0400X
NCA15640101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)