Provider Demographics
NPI:1689073314
Name:SCAVO, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:SCAVO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12755 BROOKHURST ST STE 116
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4855
Mailing Address - Country:US
Mailing Address - Phone:714-638-8277
Mailing Address - Fax:714-638-8343
Practice Address - Street 1:12755 BROOKHURST ST STE 116
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4855
Practice Address - Country:US
Practice Address - Phone:714-638-8277
Practice Address - Fax:714-638-8343
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health