Provider Demographics
NPI:1689822629
Name:CYRUS, TIMOTHY RUSSELL (MFT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RUSSELL
Last Name:CYRUS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15456
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-0456
Mailing Address - Country:US
Mailing Address - Phone:714-748-6210
Mailing Address - Fax:
Practice Address - Street 1:4201 W CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-1505
Practice Address - Country:US
Practice Address - Phone:714-748-6210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 45693106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist