Provider Demographics
NPI:1679659924
Name:VINCENT, TIMOTHY DANIEL (MPT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:DANIEL
Last Name:VINCENT
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7609 BROCKWAY RD
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:MI
Mailing Address - Zip Code:48097-3459
Mailing Address - Country:US
Mailing Address - Phone:810-387-4900
Mailing Address - Fax:810-359-9200
Practice Address - Street 1:7609 BROCKWAY RD
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:MI
Practice Address - Zip Code:48097-3459
Practice Address - Country:US
Practice Address - Phone:810-387-4900
Practice Address - Fax:810-387-9200
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008034225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP24960001Medicare ID - Type Unspecified