Provider Demographics
NPI:1689981607
Name:BERLIN, TIMOTHY A (PCC, SUPERVISOR)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:BERLIN
Suffix:
Gender:M
Credentials:PCC, SUPERVISOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7232 JUSTIN WAY
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4881
Mailing Address - Country:US
Mailing Address - Phone:440-578-8200
Mailing Address - Fax:216-378-3906
Practice Address - Street 1:7232 JUSTIN WAY
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4881
Practice Address - Country:US
Practice Address - Phone:440-578-8200
Practice Address - Fax:216-378-3906
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE,0007988-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0268768Medicaid